We conducted a total of 14 semi-structured interviews with pregnant women in Vancouver and Surrey, BC, between March and July 2020, with repetition of ideas observed at the 9th interview. As shown in Table 1, pseudonyms were assigned to each participant and demographic information was summarized. Overall, the study participants were from diverse ethnic groups, their ages ranged from 25 to 40 years, and the majority had either a university or college level education. In addition, six women out of the 14 were primigravida.
The interview lengths ranged between 28- and 65-minutes, the median time was 35 minutes. Three major themes depicted in Fig. 1 were elicited from the thematic analysis: (1) oral health experiences during pregnancy, (2) perspectives on integration and integrated prenatal oral care, and (3) strategies for addressing prenatal oral health care. Where possible, we used the participants’ own words under their pseudonyms to add veracity to their accounts .
Theme 1: Oral health experiences during pregnancy
This theme was comprised of two subthemes: oral disease experience and dental care utilization. Regarding oral disease experience during pregnancy, eight of the participants reported having bleeding gums, sore gums and/or toothache. Seven participants reported doing nothing about the observed problems, although two mentioned discussing it with their prenatal providers: “my mouth was bleeding all the time when I brushed my teeth. The doctor said it's normal and pregnancy gingivitis was common… they didn't really give me any solution” (Wendy, second pregnancy). Most participants also noted that oral health was never addressed during prenatal care, including during the health education sessions.
In terms of dental care utilization, most interviewees recounted not seeking regular care from a dental professional during their current pregnancy “even when I feel this pain, I kind of feel reluctant to go to the dentist” (Anna, third pregnancy). Dental care was sought mostly for emergency situations, including for severe toothache, and a pregnancy tumor. Only two participants visited their dentists for routine dental care; one sought care based on advice from her prenatal provider. Two other participants mentioned having their routine dental visit cancelled because of the COVID-19 pandemic. Reasons for avoiding regular dental visits included fear (particularly of the safety of dental procedures during pregnancy), lack of insurance coverage and being unaware of the need for oral health care during pregnancy. In highlighting the importance of oral health awareness, one participant told us “I have come from Pakistan where nobody knew about it [oral health] and nobody gets it checked. But then I came here nobody asked me to go to see a dentist or that you need to get it checked” (Chloe, third pregnancy). This same participant had a severe toothache during her current pregnancy and stated that her negative experience could have been averted if she were better informed.
We also heard that “dental visits are an additional cost, most people are not willing to shell out that money if they are not covered [insurance]” (Emma, first pregnancy) and that “my last pregnancy I had to borrow money to get my tooth extracted.” (Daisy, fourth pregnancy). The general view was that “dentists are expensive, and then when you get your teeth cleaned, that brings up other problems and like a never-ending pit of things that are wrong” (Kailani, fourth pregnancy).
Theme 2: Perspectives on integration and integrated prenatal oral care
We identified four subthemes: defining integrated care, the need for integrated prenatal oral care, perceived benefits of this integration, and factors influencing delivery of integrated prenatal oral care. Participants seemed to define integrated care as “multiple health care providers from different streams working together to ensure the patient's good health” (Emma, first pregnancy). Another participant explained what integrated care was not: “referral is not integrated care in my book… [there’s] very little compliance” (Gayle, first Pregnancy). This participant posited that a team approach is essential for integrated care. However, for most of the other participants, referrals were deemed critical, as is currently done with other procedures stating that “they (referrals) are really important… they're the main instrument for the integration” (Zuriel, third pregnancy).
Most of the participants voiced a need for the inclusion of preventive oral health care in prenatal care. Some considered integration a superior approach because “health care workers may not have all the answers, if another professional is able to help that would be helpful” (Wendy, second pregnancy). In particular, we heard the idea of collocating dental professionals as part of the prenatal team “to have it in one place [the prenatal team] would be like an ideal” (Wendy, second pregnancy) in the prenatal team. Two participants referred to a coordinated system whereby care coordinators are engaged to support and make appointments for pregnant women. However, some participants did recognize that the physical presence of a dentist within the prenatal health care setting might not be feasible. In this case, they highlighted interprofessional education as an important factor in achieving integration, stating that “fostering an integrated approach to learning right from medical school may be useful” (Emma, first pregnancy). Interestingly, some participants stated integrated care was not required during pregnancy because “… it's not worth doing it for a pregnancy that's going to last nine months” (Gayle, first, pregnancy).
While considering the benefits, many participants viewed an integrated approach to oral health care as “efficient in terms of time and resources” (Anna, third pregnancy). Other benefits mentioned include better health and oral health status for the pregnant woman, fewer oral health-related complications, increased oral health awareness, early diagnosis and treatment, increased trust in dental providers, equity in care delivery, and reduced stress for the pregnant woman. One participant identified the potential impact of integration on self-worth, and mental well-being stating that they “think they [pregnant women] would feel special, like valued… that would be good for self-confidence self-esteem.” (Zuriel, third pregnancy). This was consistent with comments by another participant highlighting the fact that mothers often focus on their children, and may neglect themselves, “I work 10 plus hours a day. When the day ends, it's all about my kids” (Daisy, fourth pregnancy). A few women mentioned the potential impact on the oral health of future generations: “the most important part is once mom is aware of oral health that becomes important in the baby… so that they can have healthy teeth set up for a good start to their lives” (Isabel, first pregnancy). They also commented about the timing: “if they would tell me in the start then maybe I would be more enthusiastic to go” (Chloe, third pregnancy).
The participants also identified a variety of factors that could facilitate the delivery of integrated prenatal oral care. The most commonly identified facilitator was the establishment of a simple process for addressing oral health during pregnancy “they have to have a set system in place” (Daisy, fourth pregnancy). The use of policies or guidelines regarding oral health for pregnant women was also mentioned as an important facilitator of inetgration, “the only way it would happen would be through laws and policies” (Zuriel, third pregnancy). Other facilitators identified included research evidence, advocacy, and establishment of communication channels between oral health and prenatal providers, and government support.
The participants mentioned a lack of political will, and the prevailing separate structure for care delivery as factors that could hinder integration. According to one participant, “it appears dental care is considered a separate entity… the doctor addresses your body, and the dentist will address your head and neck area” (Emma, first pregnancy). The majority of the participants identified the limited understanding of and value for oral health among non-dental health professionals and the public as a potential barrier to integration. In the words of one participant, “I think first there is this view of dental care as secondary. It's not a priority…. It's seen as like a luxury thing… It's not as important as a medical doctor.” (Zuriel, third pregnancy). They also mentioned funding as a hinderance since “some of those things are not affordable and especially if you're a stay-at-home mom. You're not covered [insurance]…” (Francesca, second pregnancy). Apathy to the idea of integrated oral health care among health providers was also mentioned: “changing anything in the health care system is difficult” (Jessica, first pregnancy), and “it's gonna take way too much time on the doctors’ side with very little interest on the dentists’ side” (Gayle, first pregnancy).
Theme 3: Strategies for addressing prenatal oral health care.
Although a few participants posited that oral health care should be addressed even before pregnancy, the majority agreed that oral health “should also be included as part of prenatal checks” (Anna, third pregnancy), different perspectives were offered on how to proceed, including recommendations relevant to pregnant women, prenatal providers, and dental providers.
In terms of relevant recommendations for the pregnant women, participants identified oral health education and funding to enable integration. Oral health education was considered vital, with one participant stating they “don't think there's like a lot of information about it out there. Not the way we talk about other things that have to do with prenatal care” (Heidi, first pregnancy). Participants supported including oral health information on pregnancy apps and other online resources, and on leaflets that could be included in the prenatal package. In addressing funding issues, many participants supported the provision of free or subsidized dental care for women during pregnancy. The most common suggestion was for preventive oral health initiatives to fall under the Medical Services Plan (MSP): “it would be pretty cool if it could be part of MSP, so we did not need to worry about the cost” (Wendy, second pregnancy). One participant also suggested the use of vouchers for those who cannot afford dental care “so that the women who need it can choose whichever dentist is closer to them” (Daisy, fourth pregnancy).
For the strategies relevant to prenatal providers, participants highlighted the role of interprofessional education. Indeed, the prenatal providers were identified as critical in the integration process because “those are the people that you're going to have the closest relationship with…” (Francesca, second, pregnancy), suggesting that “having your prenatal provider encouraging people to go to the dentist would be really beneficial” (Xena, first pregnancy) when a team approach is not present. Participants further recommended that prenatal providers should offer resources on oral health to all pregnant women. They proposed the use of oral health screening questions during the initial registration process, stating that “the prenatal care provider should probe if somebody would need to go to the dentist or not” (Francesca, first pregnancy). Although interprofessional education was suggested, there were mixed reactions to prenatal providers conducting oral examinations. Approximately half of the participants thought it would be acceptable, while the others preferred that trained dental providers conduct oral examinations: “because they're not oral health professionals. I don't think that's their task” (Zuriel, third pregnancy). One participant also specified that oral examinations by non-dental providers may be undesirable to women with previous negative experiences such as a history of trauma.
For strategies relevant to dental providers, whether or not they are within the prenatal health care team, many participants suggested a dental provider should be visited during pregnancy with some stating that “I just feel there should be one compulsory visit to a dentist” (Anna, third pregnancy) in order to “check teeth, gums, to see if there are small issues that could be resolved” (Zuriel, third pregnancy). The participants proposed that dental providers should perform basic dental care, including dental checks, and cleaning for all pregnant women, while other non-urgent procedures should be delayed until after pregnancy. Many participants also suggested that dental providers should be advocates for the delivery of care to pregnant women.