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Abstract
Objectives This study aimed to gain a comprehensive understanding of the determinants that influence oral healthcare behaviours among Iranian pregnant women.
Study design Qualitative study.
Setting Comprehensive health service centres.
Participants A sample consisting of all people involved in the process of oral care during pregnancy, 18 pregnant women, 7 midwives/healthcare workers, 3 supervisors of prenatal care services and 3 dentists) were purposefully sampled in terms of demographic characteristics.
Methods The qualitative content analysis study conducted 31 semistructured individual interviews in 2022, utilising MAXQDA V.10.
Results The participants identified 3 main categories and 11 subcategories: individual and physiological determinants (care needs, perceived importance, motivation, oral health literacy and inherent pregnancy limitations), organisational determinants (costs, access to equipment and services, review of service delivery process and professional behaviour) and social-cultural determinants (educational services and support from family and friends).
Conclusions The results can be used in interventions to improve oral healthcare for pregnant women. This study highlights the importance of addressing individual, organisational and social-cultural determinants to improve oral healthcare during pregnancy.
- QUALITATIVE RESEARCH
- Primary Care
- Health Education
Data availability statement
Data are available upon reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
Semistructured in-depth interviews allowed a rich exploration of the participants’ perspectives to explore new and emerging concepts in oral healthcare in pregnancy.
A multistakeholder perspective on prenatal oral health to obtain a comprehensive understanding of insights into the perspectives of pregnant women, midwives/healthcare workers, supervisors of prenatal care services and dentists in a broad and diverse range of different education levels and work experiences.
Triangular analysis was performed by three researchers who clarified their assumptions before starting the study.
Due to the restrictions caused by the COVID-19 pandemic, the use of group discussions to better understand the findings was not possible.
Views of pregnant women who do not visit government health centres were not explored.
Introduction
Pregnancy can lead to changes in a woman’s body that can affect her oral health, making it a time of particular vulnerability in oral care. Most pregnant women experience toothache and periodontal diseases during pregnancy due to tooth decay.1 In addition to the final cost of oral and dental disease, pregnant women bear the potential for adverse pregnancy outcomes, including premature birth, low birth weight babies,2 3 and increased dental caries in children after birth.4
Previous studies have pointed out the difference between the oral health needs of pregnant women and the general population. Several studies have shown that oral and dental diseases harm the quality of life and health perception of pregnant women.1 5 The WHO recognises the importance of oral and dental hygiene as part of preventive measures in healthcare for pregnant women and newborns.6 Despite guidelines and institutions recommending dental care during pregnancy, many pregnant women of different ages do not seek treatment, and this serious health problem is often ignored.2 The results of a population-based study during 2014–2015 among 4071 Iranian pregnant women in 10 different provinces showed that about 55% of pregnant women are not visited by a dentist during pregnancy.7 More than half of Iranian pregnant women brush their teeth once a day, and the average DMFT score of pregnant women was reported as 3.93±5.64.8
Pregnant women may not have enough knowledge about the effects of their oral health on the fetus and the consequences of their pregnancy.9 Some pregnant women may refuse to go to the dentist despite knowing the clinical condition of their oral health due to incorrect knowledge.10 Others may think that poor oral hygiene during pregnancy is normal.11 Pregnant women may have a negative attitude towards oral care during pregnancy due to incorrect information and fear of the adverse effects of dental procedures on the mother and fetus. This negative attitude can lead to poor oral health during pregnancy and is associated with an increased risk of adverse pregnancy outcomes.12 However, evidence shows that oral healthcare during pregnancy is safe and should be recommended to improve the oral and general health of the woman.13 14
Many pregnant women in Iran do not go to health centres for oral care during pregnancy due to limited knowledge, attitude and lack of a coherent structure for oral care.15 16 However, it is crucial to pay attention to the importance of oral health during pregnancy for those involved in the oral care of pregnant women and newborns.17 Prenatal care providers play a crucial role in supporting and providing preventive oral care during pregnancy. By working together, physicians and dentists can help pregnant women initiate and maintain oral healthcare during pregnancy and through the life span, improving the oral and overall health of both the mother and baby.18
Since mothers are responsible for establishing healthy habits in their children at an early age, public health programmes can help prevent adverse health outcomes for both the mother and baby and establish healthy habits in children at an early age by prioritising maternal oral health during pregnancy.
While various studies have examined the factors affecting oral care during pregnancy, few studies have comprehensively examined these factors at all individual and social levels. Therefore, more research is needed to discover, describe and explain these factors in the oral healthcare of pregnant women from a qualitative perspective. Qualitative research is a suitable method to gather people’s opinions about their experiences and clarify concepts and relationships between them. This study benefits from using qualitative content analysis, which enables the exploration of pregnant women’s experiences in an open and non-judgemental way, simulation of individual experiences and objective data analysis without being influenced by prior judgements or biases. Qualitative content analysis is a valuable research method that can help identify factors that may be missed by quantitative research.19
Therefore, the content analysis approach is an appropriate method to attain a comprehensive and deeper understanding of the factors affecting oral health in oral care, especially considering the sociocultural and organisational conditions governing society in pregnant women.20
The study aimed to answer the question, ‘How do pregnant women and prenatal oral healthcare providers understand oral healthcare during pregnancy’.
Materials and methods
Study design and participants
This study used a content analysis approach based on a guided approach.21 This study was conducted and reported according to the Consolidated Criteria for Reporting Qualitative Research22 (online supplemental file 1).
Supplemental material
Consolidated criteria for reporting qualitative studies (COREQ)Pregnant women were sampled through comprehensive health service centres. Oral health providers who were working there were also included in the sample. The sampling method was purposeful with maximum diversity. Pregnant women in different age groups, gestational age, education and economic status of the family were invited. Also, oral health providers were selected from all levels of the health system in terms of education, work experience, and different health centres.
The inclusion criteria for pregnant women to enter the study were as follows: over 18 years old, a pregnancy age of at least 20 weeks, being Iranian and living in Mashhad City. The oral health workers in the study were dependent on two criteria: having at least 1 year of work experience and the ability to express their experiences, opinions and views. Participants who did not want to continue cooperation or were not satisfied with recording the conversation were excluded from the study. Finally, after interviewing 18 pregnant women, 7 midwives/healthcare providers, 3 supervisors of prenatal care services and 3 dentists, the data reached saturation.
Patient and public involvement
The public and patients were never involved in study design or management.
Data collection
Data were collected using a guide questionnaire and semistructured interviews employing individual interview techniques. The guiding questions were tested through four interviews with pregnant women to determine the time required, people’s reactions and the need for additional questions. The interview questions were modified and new questions were added as the study progressed. At first, 17 questions for pregnant women and 15 questions for oral health workers were included, which finally changed to 18 and 11 questions (online supplemental file 2), respectively; all the interviews were conducted by a female doctoral student of health education and health promotion who received comprehensive practical training in the field of conducting qualitative studies and was interested in conducting studies in the field of improving oral care. Participants were identified by visiting selected health service centres, and the interviews were conducted at a time and place convenient for the participants. There was no other person present at the interview place.
The interviews began with an introduction of the researcher and the purpose of the research to establish communication and gain the participants’ trust. The interviews were conducted face-to-face based on guided questions, and all conversations were recorded by a recording device. Probing questions were used during the interviews to further reveal the answers to ambiguous questions. Examples of probing questions include ‘Can you give an example?’ and ‘I do not understand what you mean, please explain more’. The duration of each interview varied between 15 min and 45 min, and interviews continued until data saturation was reached. Efforts were made to avoid giving feedback, inducing opinions to the participant, and correcting their statements, according to the purpose of the interview.
Data analysis
The process of content analysis is carried out with a guided approach using SE and Shannon’s method during three stages of preparation, organisation and reporting of findings.21
In the preparation stage, the researchers use the intervention mapping model to create an interview guide and resolve ambiguities in the text. The intervention mapping model is a theory-based and evidence-based health promotion programme planning model that takes an ecological approach to understand health problems and to intervene at multiple levels, including individual, interpersonal, organisational and community levels.23
In the organisation phase, the standard method of analysis is used to determine semantic units and primary codes, which are then compressed and summarised with appropriate labels. The next step is to form categories from subcategories, and as the researcher’s understanding of the primary codes increases, more abstract codes develop. In the reporting of findings phase, the researchers provide a rich background of the phenomenon under investigation and create an understandable description with sufficient interpretation for the reader. The data are organised using MAXQDA V.10 software.
To confirm the research, triangular analysis was performed by three researchers who clarified their assumptions before starting the study. The full text of all interviews and extracted classes approved by supervisors, consultants and experienced individuals in qualitative studies. Additional comments from these people were used in all stages of implementation, coding and extraction in primary categories. The transferability of this study was ensured by selecting samples from different socioeconomic classes and educational levels as well as diverse groups. In addition, findings were compared with those of people who were in similar situations to the participants.
Results
Sample characteristics
In this qualitative research, 32 pregnant women and 15 oral health workers were invited to participate in the study, 31 participants were interviewed, and the findings reached saturation. The main reason for refusing to participate was due to the restrictions caused by the COVID-19 pandemic. Pregnant women with an average age of 24.5±29.83 were in different months of pregnancy. Of 50% (n=9) had previous pregnancy experience, and about 72% (n=13) were housewives. The average age and work experience of oral health workers were 55.84±7.03 and 17.61±7.26, respectively. Other demographic characteristics of the participants are given in table 1.
Participant demographic characteristics in the qualitative study
Qualitative results
The 1220 primary codes extracted from the data analysis were organised into 11 subcategories, which were categorised into three main categories as presented in table 2.
Views of pregnant women about the determinants of their oral healthcare
Individual and physiological determinants
The first category was divided into five subcategories, and it includes determinants related to the pregnant woman herself.
Oral health literacy
The participants reported that certain factors such as awareness, education and shaping behaviour can increase oral care in pregnant women. However, some participants regarded oral issues during pregnancy as a regular part of the process.
Every mother believes a tooth must be lost with each pregnancy and breastfeeding. This is a natural occurrence for them, but they are unaware that it can be prevented (midwife, 15 years of experience).
If we had more information about oral health, we would be more likely to take care of our teeth regularly (pregnant, ages 25–30 years old).
Also, the participants recommended institutionalising oral care from childhood and strengthening the culture of prevention and timely treatment.
All study participants expressed that they needed training on how to provide care, especially for pregnant women.
It would be helpful if someone could teach which type of toothpaste is suitable for use during pregnancy, and which type of toothbrush is good if it is taught, that is good (pregnant, ages 25–30 years old).
Perceived importance
Several oral health providers reported that it is crucial to raise awareness among pregnant women about the significance of oral health and sensitivity toward oral diseases. However, they stated that pregnant women do not prioritise oral hygiene.
It doesn't matter to them; they don't think about it. My tooth is a part of their body, like the leg, like the head. They say very easily, well, now it is broken, throw it away (dentist, 6 years of experience).
Pregnant mothers don't care about their teeth as much as they care about their other physical issues, which means they haven't developed the belief that their dental health is as important as the health of their other body parts (supervisor of prenatal care services, 28 years of experience).
Care needs
Participants’ statements suggest that practising behavioural skills such as using toothpicks, dental floss, brushing and attending dental examinations can be effective in prenatal oral care.
The most important and main way is that in the pre-pregnancy period when she wants to get pregnant, her dental examinations should be done with the knowledge of why they need to go and what they need (dentist, 6 years of experience).
Also, Healthcare providers and midwives recommend that due to pregnancy conditions, pregnant women should observe their oral hygiene more than before pregnancy.
Motivation
Several factors that increase prenatal oral care include application incentives, reducing fears, motivating patients and prior experience. A few participants raised the fear of complications for the fetus as a reason why pregnant women may be less motivated to perform medical visits during pregnancy. With the spread of the COVID-19 epidemic, one of the concerns of pregnant women when visiting the dentist was the fear of contracting the coronavirus.
Currently, because of the coronavirus situation, the pregnant mother herself does not like to take off her mask or, for example, take care of her mouth and teeth (healthcare, 12 years of experience).
Restriction of the nature of pregnancy
Participants reported that pregnancy-related physical discomfort and fatigue can hinder oral hygiene maintenance. Focusing on prenatal oral care can be improved by managing drug use, stress, morning sickness and changing habits.
Boredom and lethargy in this period; It means that the mother has been lethargic from the beginning.
She is not bored with anything… She does not like to do anything (midwife, 15 years of work experience).
Organisational determinants
The next category, which environmental-organisational factors that facilitate oral healthcare behaviour, was divided into four subcategories.
Costs
The participants frequently reported barriers to oral care for pregnant women, such as high dental costs and inefficient insurance. Most people believe that the cost of dental services in Iran is very high, which is one of the main obstacles to not visiting a dentist.
Pregnant mothers never go directly to the dentist because of the high costs of dentistry (midwife, 17 years of experience).
Iran has made significant progress in improving its healthcare system over the past few decades, but there are still concerns about the effectiveness of health insurance in protecting against high costs.
I think work insurance can be useful. It should be insurance that can pay part of the expenses … most dentists do not accept insurance (pregnant, ages 25–30 years old).
Access to equipment and services
Respondents in this study stated that they do not have access to a written educational package for oral care during pregnancy. The oral health providers have expressed concerns about the ever-increasing tariffs and lack of access to dental services for pregnant women. They suggest that revised care guidelines should place greater emphasis on prenatal oral health.
Unfortunately, now the tariffs have increased. That is, our dental tariffs have increased recently at the beginning of the week, and this makes the number of visits to our centers much less (supervisor of prenatal care services, 24 years of experience).
Review the service delivery process
Organisational support, referral system importance, health centre limitations and teamwork can improve prenatal oral care. Most participants, including midwives, and dentists, considered collaboration and coordination among the care team to be significant to ensure the oral health of pregnant women. The study also found that most participants mentioned the need to pay more attention to the referral system and monitor the process more closely.
For this, a group must work together. The team includes healthcare workers, midwives, center doctors, nutritionists, mental health experts, husbands, and everyone involved. The midwife’s work is not alone, but this group must all work together (midwife, 15 years of experience).
Professional behaviour
Pregnant women have reported that their willingness to perform oral care is affected by factors such as inappropriate behaviour of oral health service providers and a lack of commitment from dentists to work in comprehensive health service centres.
They argued with me badly and told me to go, take back the money you paid, and leave until this time(pregnancy) was over (pregnant, ages 20–25 years old).
The dentist does not work… The dentist says I have no more energy. Dentists at the health center are not very busy… most of them are unemployed (pregnant, ages 25–30 years old).
Social-cultural determinants
The third category of factors affecting oral healthcare was social-cultural determinants, which was divided into two subcategories.
Educational services
Participants stated that factors such as the use of media and educational resources can increase prenatal oral care. They believed that most of the education provided in the health system is more traditional and does not have the necessary efficiency. New educational techniques incorporating social media and written content can be effective, especially in virtual spaces. From the point of view of the participants, social media can be an effective tool for oral healthcare.
Other internet channels, such as WhatsApp and Telegram, are much better for pregnant mothers. For example, to increase general information about pregnant mothers, those who are members of the health service, and who are pregnant, should be on the same channel (pregnant, ages 25–30 years old).
Support from family and friends
Participants often reported the supportive role of family and the importance of drawing on the experiences of the entourage. They also stated that husbands can support family oral health by prioritising their wives’ prenatal oral health. This indicates low social support for oral care, resulting in decreased continuity and consistency of care.
On the other hand, it is the support of their wives, because many people say, for example, my husband says that he does not want you to fix it, now you will pull your teeth later. In my opinion, awareness should be created for men in this field that the risk (of dental problems) is higher (dentist, 10 years of experience).
Discussion
Main findings
The study aimed to provide a comprehensive understanding of the determinants of oral healthcare among Iranian pregnant women. The study examined oral healthcare behaviour in pregnant women from multiple perspectives, including midwives/healthcare workers, supervisors of prenatal care services and dentists. The results provide a coherent and complete picture of the determinants of oral healthcare behaviour during pregnancy.
This study suggests that oral health literacy and understanding the importance of oral healthcare are crucial factors in preventing tooth decay during pregnancy. The results of a 2020 study on oral health literacy among 169 pregnant women in Kerman, Iran, indicated insufficient literacy levels. The study highlights the necessity of dental consultation before pregnancy to improve oral health literacy among pregnant women.24 Another study on the oral health literacy of 2263 pregnant women suggests that it is necessary to improve the oral health literacy of pregnant women with the help of education.25
This study found that pregnant women often neglect their oral and dental hygiene due to a lack of attention given by oral healthcare providers and insufficient education and sensitivity provided to pregnant women. As a result, pregnant women tend to rely on unprofessional oral care. Most of the participating pregnant women stated that they need to receive the necessary training from prenatal care providers in this field, especially in the first level of prevention. Oral healthcare providers need to prioritise and educate pregnant women about the importance of maintaining good oral and dental hygiene during pregnancy. However, it is possible that pregnant women may not receive professional training due to a lack of understanding of the importance of oral care during pregnancy and may disregard the training provided by oral healthcare providers.26 According to a 2019 study, one of the most significant reasons for not using oral healthcare is the lack of awareness of its importance. This issue was identified as an intergenerational responsibility, meaning that the health status of one generation can influence that of the next.27
The participants suggested that the habit of performing oral care should be institutionalised in the individual from childhood, and the culture of prevention and timely treatment should be strengthened. The results of previous studies emphasised the comprehensive education of pregnant women about the importance of oral health during pregnancy.28 29
From the participants’ point of view, performing examinations before and during pregnancy plays a vital role in maintaining oral health. However, access, attitude and awareness of women before pregnancy should be improved.13
The oral health providers in the study suggested reinforcing positive behaviours and correcting negative behaviours in mothers. Pregnant women can benefit hugely from education that promotes caring behaviours and minimises the limitations of pregnancy. Improving oral health outcomes during pregnancy can be achieved through regular dental care, education, broader oral health coverage, routine oral health maintenance and access to resources. The results of various studies in Iran also indicate the effectiveness of education on the awareness of pregnant women in this area and the promotion of oral care behaviours.30 31
Several factors, including lack of time, high cost and fear of complications for the fetus, can cause reluctance to receive dental services during pregnancy, as highlighted by Mousa et al’s study in 2019; However, encouraging regular dental care, providing education, advocating for broader oral health coverage, reinforcing routine oral health maintenance and informing pregnant women about the importance of oral health can all contribute to improving oral health outcomes during pregnancy.32
Bao et al’s study evaluated and summarised clinical practice guidelines on the prevention, diagnosis and treatment of dental diseases during pregnancy. The study found that published clinical guidelines provide clear messages and guidance to dentists for providing timely and safe care during pregnancy.33
Most participants found dental services too expensive, hindering dental visits. Pregnant women may face significant financial constraints when it comes to receiving oral care. According to a population-based study conducted among Iranian women in 2019, the main reasons for not receiving oral services during pregnancy were lack of perceived need and financial barriers.
In Iran, oral care services are not completely covered by health insurance, which means households have to pay high out-of-pocket expenses to receive oral care.34 Evidence suggests that having insurance coverage can significantly improve access to oral health services, enhance service quality and reduce financial barriers to utilisation.35 However, lack of adequate insurance coverage, incomplete oral services in public sectors, people’s lack of trust in their quality, poor access to services and customer dissatisfaction are among the problems of oral services provided in public health centres in Iran.
Health professionals are concerned about the ever-increasing tariffs and the lack of access for all pregnant women to oral services in Iran. Oral care guidelines in pregnancy should be updated to prioritise oral health. Also, it is essential to have seamless cooperation and coordination between healthcare providers, such as midwives, obstetricians and dentists, to ensure optimal oral healthcare for pregnant women. A study conducted in 2021 suggests that interprofessional collaboration can significantly improve oral healthcare utilisation.36 The effectiveness of the referral system and patient-centred care team in reducing oral diseases among pregnant women has been emphasised in various studies.37 38
Participants in a study emphasised that effective communication and interaction among healthcare team members, particularly dentists, are crucial for performing oral care practices. Therefore, dental professionals must develop and maintain strong interpersonal communication skills to establish trust and enhance patient satisfaction with their care previous studies have also confirmed this finding.39 40 The participants suggested that Telegram and WhatsApp are promising platforms for promoting oral health among pregnant women. A study conducted in 2020 also highlights the potential of smartphones and social networks as an initiative to promote prenatal oral healthcare.41
The participants in the study emphasised the importance of family, government and cultural support to maintain oral health and improve self-care behaviours. In line with our findings, according to a 2019 study, women whose medical providers promoted oral healthcare were nearly wo times as likely to have a dental visit during pregnancy.40 Therefore, health centre education can influence dental visits during pregnancy.
Educating oral health in families, encouraging dental visits, integrating oral health into general health and paying specific attention to prenatal oral health are some recommendations that can implemented to improve oral healthcare for pregnant women in Iran.
Limitations
There were some limitations to this study. The results of the study may not be generalisable to pregnant women who do not visit public health centres. Another constraint was that the pregnant woman’s socioeconomic status might have affected her oral health. Maximum diversity sampling was used to recruit participants from all health centres in different areas of the city. Also, Group discussions could have contributed to a deeper understanding of the concepts but were not carried out due to restrictions caused by the COVID-19 epidemic.
Implication for future research
This study may contribute to future research on needs assessment to create a new specific scale of oral care in pregnancy and improve training programmes. However, more cross-sectional studies are needed to evaluate all perspectives and establish causal relationships between variables.
Conclusions
Considering the increasing importance of oral and dental health in pregnancy and the existence of health guidelines in this field, there is a fundamental need for a deeper understanding of the experiences and determinants of oral and dental care. By providing an image of the factors affecting the oral care of pregnant women at different individual, physiological, social-cultural and organisational levels, this study emphasises the importance of understanding the unique needs and experiences of pregnant women in research and healthcare settings.
Data availability statement
Data are available upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by the Ethics Committee of Mashhad University of Medical Sciences with ethics code IR.MUMS.REC.1399.323. Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The study authors express their sincere gratitude to all authorities of the Student Research Committee of Mashhad University of Medical Sciences and all the study participants.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors All authors participated and approved the study design. MGholian-aval contebuted to designing the study. MAbdollahi collected the data. MAbdollahi,HT,MM and AN_K, analysed the data. The final report and article, were written by MAbdollahi, MM, HT and MGholian-aval and all authors read and approved the final manuscript. MGholian-aval was a guarantor who has full responsibility for the work and the coduct of the study, had access to the data andcontrolled the decision to publish.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer-reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.