Sample
The focus group of pregnant and parenting women were 27 to 32 years of age, with a mean age of 28.4 years. The individual interviews were completed with four social workers, three medical providers (one PCP and two OBGYN), and three dental providers (one hygienist and two community dentists). All participants were female, 34 to 63 years of age, with a mean age of 47.9 years. We reached data saturation by the end of study, when we were no longer receiving new information from additional interviewees.
Women’s Experiences of Oral Health Problems During Pregnancy
The focus group of pregnant and parenting women repeatedly reported experiencing dental problems during pregnancy. Many reported not knowing the importance of maintaining good oral health during pregnancy and described seeking dental care during pregnancy as “frustrating” and “did not know it’s needed”.
Parenting woman: “I had issues with my gums, probably at mid pregnancy, it started swelling, bleed and hurt. But I didn't go to the dentist. I just kind of dealt with it.”
Barriers and Facilitators
Comments from all five types of informants were categorized as barriers, facilitators, and strategies or implications for policy-making. Table 1 illustrates the representative quotations. Table 2 summarizes the themes from our analysis of participant comments, separated into identified individual and system-level factors.
Individual-level barrier theme 1 - Socioeconomic hardships and competing interests
A commonly recognized barrier to medical care utilization, socioeconomic hardships, and competing interests, also represents a barrier to utilization of prenatal oral health care. Pregnant/parenting women reported that they could not get to their dental appointments due to lack of babysitting, lack of transportation, and priority of other life events.
Individual-level barrier theme 2 - Lack of awareness of benefits and importance
Another barrier is unawareness of the benefits and importance of prenatal oral health care among pregnant women. Many pregnant/parenting women reported rarely knew the association between poor oral health and adverse birth outcomes, and the importance of maintaining oral health during pregnancy.
Individual-level barrier theme 3 - Lack of awareness of dental coverage from medical insurance
A unique barrier identified is unawareness of dental coverage from medical insurance. A majority of the medical providers, community/social workers, and pregnant/parenting women did not know about the dental coverage by the Medicaid insurance. In addition, they were not familiar with the source of dental clinics that accept Medicaid insurance.
System-level barrier theme 1 - Inadequate inter-professional collaboration
Intriguingly, all participating medical providers, dental providers, community/social workers, and pregnant/parenting women recognized insufficient inter-professional collaboration in promoting prenatal oral health. A majority of the informants acknowledged that the initial introduction of the importance of prenatal oral health should come from medical providers.
System-level barrier theme 2 - Lack of awareness of prenatal oral health guidelines
We identified another system-level barrier as unawareness of the latest practice guidelines among medical, dental providers, and community/social workers. Although some of them knew certain types of prenatal oral health guidelines, none of them were aware of the latest practice guidelines and the recommendations from professional organizations, such as the American College of Obstetricians and Gynecologists or the American Dental Association, both of which clearly state that conditions that require immediate treatment, such as examinations, extractions, root canals, and restorations are important and safe to perform at any time of the pregnancy [26]. Some OBGYNs said they continue receiving requests form dental providers of their pregnant patients for medical clearance to initiate dental treatment. This unfamiliarity of the guideline was echoed by other participating dentists, who reported avoiding providing dental treatment to women during their 1st trimester, for which the ACOG and ADA recommend as a safe period for receiving dental care.
System-level barrier theme 3 - Insufficient dentists providing treatment to underserved pregnant women
Both medical providers and community/social workers reported that they had referred patients for dental care, but unfortunately, some of their patients were denied dental care due to the pregnancy. Furthermore, the pregnant/parenting women expressed that limited dental clinics accepting their insurance and the long waiting lists exacerbated their unwillingness to visit a dentist during pregnancy.
Facilitators
Individual-level facilitator theme 1 - Constant reminders
A critical facilitator that pregnant/parenting women proposed was “constant reminders.” Participating women stressed the importance of these reminders, which should be introduced by their maternal doctors as early as their first pregnancy visit, and repeated at their follow-up pregnancy appointments.
Individual-level facilitator theme 2 - Raise community awareness via mass media
Pregnant/parenting women suggested raising community awareness via mass media as an essential facilitator to improve the use of prenatal oral care. They recommended the use of commercials, campaigns, bus stop advertisements, health fairs, and community events.
System-level facilitator theme 1 - Strengthen interprofessional collaboration
Strengthening interprofessional collaboration was proposed as a strong facilitator to promote the use of prenatal oral health care. The medical, dental providers and community/social workers specifically commented on several pivotal points that are crucial to a sustainable interprofessional collaboration, including merging the medical and dental electronic record systems, shortening physical distance between prenatal medical and dental offices, creating billable prenatal oral health counseling services, and enhancing collaborations with social service groups.
Innovative Entry Points for Prenatal Oral Health Care Promotion
Through this study, we furthered mapped the elements of real and virtual community with which women interact during pregnancy, demonstrated in Figure 1. The map reveals the potential entry points through which we can promote prenatal oral health to the majority of the underserved pregnant women. These include traditional medical contacts through maternal providers; traditional social circles such as community groups, family and friends; social benefit support groups; children’s community circles (e.g. daycare), and social workers. What stands out as an innovative entry point is the virtual community, through which social media and smartphone apps can spread information.
Parenting woman: “Nowadays, most people will use smartphones. Smartphone will be a good way for patient to get oral health information. For example, if they are pregnant or breastfeeding, they can download an app with professional dental knowledge plugin at every different stage. When they are reviewing pregnancy or breastfeeding related information, noticeable pictures and videos will provide better oral health education, not only for moms, but also for young children.”
Parenting woman: “It should be a commercial somewhere, whether it's Facebook and it could be played between a popular show that everyone is watching.”
OBGYN: “Many of our moms are members of online support groups. I think Text-for-Baby is one that connects moms with knowledge they need to know during pregnancy."