Knowledge, attitude and practices of women regarding oral and dental health care during pregnancy

Introduction

Pregnancy is a natural process that may create some changes in different parts of the body including the oral cavity. These changes will lead to oral diseases if enough and timely care of oral cavity is not taken. Women may experience increased gingivitis or pregnancy gingivitis begins in the second or third month of pregnancy that increases in severity throughout the duration of pregnancy. Pregnancy is associated with immunologic changes, particularly suppression of some neutrophil functions, are the probable explanation for the exacerbation of plaque-induced gingival inflammation during pregnancy. Oral health screening is not a routine procedure in many antenatal clinics, and there are no standard guidelines which ensure that all pregnant women are routinely screened, treated, or referred to specialized dental professionals as part of prenatal care.⁽¹⁾

Women are more liable to oral health problems during pregnancy. This is at least partly because increased levels of estrogen and progesterone during pregnancy lead to exaggerated gingival tissue response to dental plaque, thereby increasing the risk of gingivitis.⁽²⁾ Pregnancy may affect teeth far less than teeth and their periodontal environment in particular, may endanger pregnancy. ⁽³⁾

Women need to be aware of the importance of oral health care during and after pregnancy for themselves as well as their children. ⁽⁴⁾Regular dental visits and daily oral hygiene are important components of oral health care, which is an integral part of general health. Poor oral health can impact the quality of life and well-being of pregnant women by causing suffering and pain and affect the ability to eat, drink, swallow, maintain proper nutrition, and communicate. Further, the relationship between poor oral health and systemic diseases has been increasingly recognized over the past two decades. ⁽⁵⁾

 However, health professionals often do not provide oral health care to pregnant women. At the same time, pregnant women, including some with clear signs of oral disease, often do not seek or receive care. In many cases, neither pregnant women nor health professionals understand that oral health care is an important component of a healthy pregnancy. ⁽⁶⁾

Nurses are extremely important to care of patients in all aspects of their health. They are in an ideal position to screen for dental disease, refer for dental care and promote good oral health of pregnant women.⁽⁷⁾It is well recognized that one of the aims of antenatal care is to improve general maternal well-being. For many years, an underrated part of this care included an attempt to improve the dental health of mothers during their pregnancy and to educate them about the dental healthcare of their babies. This is becoming important subject as periodontal disease has been shown to increase the risk of adverse pregnancy outcomes. ⁽⁸⁾

Dental care professionals should render all needed dental services to pregnant women, regardless of their stage in pregnancy. It is not necessary to have approval from the prenatal care provider for routine dental care of a healthy patient. They should also be ready and willing to provide emergency/acute care at any time during pregnancy as indicated by oral condition. ⁽⁹⁾

Justification of the problem:

Most women do not access oral health care during pregnancy despite evidence that poor oral health can have an adverse impact on the health of a pregnant woman and her child. ⁽¹⁰⁾Researchers have shown a possible link between poor maternal oral health and adverse Pregnancy outcomes such as low birth weight and premature birth. Good oral health and control of oral disease protects a woman's health and quality of life before and during pregnancy, and has the potential to reduce the transmission of pathogenic bacteria from mothers to their children. ⁽¹¹⁾, Oral health care needs to be addressed by a multi-professional approach and should be integrated into comprehensive health-promoting strategies and practices.⁽¹²⁾ Therefore, it is important to understand pregnant women’s oral health knowledge and behaviors and to identify barriers to accessing care and practicing good oral hygiene. ⁽¹³⁾ So the present study will be done to assess pregnant women knowledge, attitude and practices regarding oral and dental health during Pregnancy

Aim of the Study

This study aims to: assess pregnant women knowledge, attitude and practices regarding oral and dental health during Pregnancy.

Research question:

1-       What is the level of pregnant women Knowledge regarding oral health during pregnancy?

2-       What is the attitude of pregnant women regarding oral health during pregnancy?

3-       What is the practice of pregnant women regarding oral health during pregnancy?

4-       Is there is relationship between knowledge, attitude and practice of pregnant women and socio demographic data?

Subject and Methods:

 A descriptive cross-sectional research design was utilized to accomplish this study. It was conducted in MCH centers in Minia city (first child health center MCH center and west MCH center)These centers provides services for all pregnant women who are attending MCH centers seeking  for antenatal care  services  either  coming  from rural and urban areas in Minia  City.  A purposive sample of 300 who are seeking medical advice, this sample detected by using (Epi- info ^tm statistical package; version 6) with 39% proportion of good Knowledge and practice at 95% level of confidence (CI) ⁽¹⁴⁾,  

Pregnant women attending antenatal Clinic services were enrolled in the study and excluded any women with any medical disorders.

Tools and technique of data collection:

Data of this study was collected by using:

1. Structured interviewing questionnaire: This tool developed by the researcher after reviewing the related literature and translated to Arabic form by the researcher It was divided into 2 parts and Consisted of (8) questions of closed-ended types:

 It consists of two parts: 

• 1^st Part: this part contained questions to assess women's socio demographic characteristics (Assessment sheet) such as (age, level of education, residence, occupation and total income of the family) (Questions: 1- 5), it took 5 minutes to be completed by researcher.
• 2^nd Part: this part contained questions to assess women's Obstetrical history such as: (Number of gravidity, parity and gestational age) (questions: 6- 8), it took 5 minutes to be completed by researcher.

1. Woman knowledge assessment tool

This tool contained Assessment Knowledge Questionnaire sheet about oral health (Knowledge Assessment) such as: (questions: 9- 16), it took 10 minutes to be completed by researcher.

Scoring system of knowledge:

An answered question   with yes was scored 1 and the answered question with no scored zero. For each area of knowledge, the scores of the items were summed-up and the total divided by the number of the items, giving a mean score for the part. We constructed a "dental knowledge score" by counting the total number of acceptable answers given by the subjects, the dental knowledge score was in an interval scale and ranged from 0 to 10, with a higher dental knowledge score indicating better dental knowledge. The knowledge scores were regrouped into 2 categories: those with good oral health knowledge and those with poor oral health knowledge. Thus a score of 6 and above was graded as good knowledge, while 5 and below was graded as poor knowledge.

1. Women’s attitude assessment  sheet:

This tool contained statements on oral health during pregnancy assessed women's attitude about oral health by the likert scale (with 2 responses agree and disagree for each statement) (questions: 25- 34), it took 10 minutes to be completed by researcher:

Scoring system for attitude:

An answered question with agree was given the score “one” and “zero” for disagree, the scores of the items were summed-up and the total divided by the number of the items, giving a mean score for the part.  The subjects were asked to indicate whether they agreed with, dis agreed with a dental attitude score was then computed for each respondent by counting the total number of statements to which the respondent displayed positive oral health attitude. The maximum achievable score was 10 with a higher score indicating a more positive attitude. Individuals with scores of 7 and above were graded as having positive attitude to oral health.

1. Women self-practice assessment sheet

This tool contained questions to assess women's self-practices about oral health (questions: 35- 52), it took 10 minutes to be completed by researcher.

Scoring system for practice:

We constructed a "dental practice score" by counting the total number of acceptable answers given by the subjects, the dental practice score. Was in an interval scale and ranged from 0 to 14, with a higher dental practice score indicating better dental knowledge. The practice scores were regrouped into 2 categories: those with good oral health knowledge and those with poor oral health knowledge. Thus a score of 8 and above was graded as good practice, while 7 and below was graded as poor practice.

Content validity and reliability:

All tools of data collection were  reviewed for validity from supervisor and jury committee consist of three professors' specialists of obstetric nursing  for all steps of research process, According to the guidance of committee the researcher were modified the tools of data collection. Reliability: Give the same tool twice, separated by days for the students.

Pilot study:  A pilot study conducted on 10 % (30 pregnant women) of total sample to test the tools for the clarity, applicability, feasibility, and for all research process steps, to find the possible obstacles and problems that might be faced during data collection. Then necessary modifications were carried out and the subjects were excluded from the study to avoid contamination of the selected sample.

Field work:                               

An official letter was sent from the dean of the Faculty of Nursing at El-Minia University to head manager of Minia MCH centers, asking for permission to collect data.

Interviewing phase:

The researcher attended to MCH centers to collect the data per 3 day from 9.00 AM to 1.00 PM in three days each week within average of one hour for each woman, during which the aim and nature of study briefly explained through direct personal communication with the participant and formal consent obtained from the participant (verbal or written) before inclusion in the study this phase was took about 15 minutes.

Implementation phase:

During this phase  the researcher  interviewing by herself  the participants who were agreed to participate in the study, using tools of data collection, all women were assessed for socio demographic characteristics, and obstetric history then they were evaluated for their knowledge, attitude and self practices  regarding dental care,  this phase took about 30 minutes by the researcher for each case. 

Ethical considerations:

The study protocol was approved by pertinent research and ethics committees at the Faculty of Nursing in El-Minia University. An official permission was obtained by submission of an official letter from the responsible authorities of the study setting (MCH centers) to obtain the authorization for data collection. The aim of the study was explained to the participants, along with the benefits and any potential risks or discomforts. Oral consent was obtained from women after the researcher explained the general aim of the study. Participation was volunteer and any participant could deny participation at any time at no cost. Data was kept confidential and was used solely for research purposes.

Limitations of the study:

• It was somewhat difficult for the researcher to encourage and to motivate some women to participate in the study such as many of women  were rushed and busy with other household things and had no time so refused to participate in the study
• Sometimes the flow rate of cases  during the day of collecting data were low
• Many of cases were missed due to exclusion criteria     

Statistical analysis

Data were entered and analyzed by software SPSS version 19 Qualitative data presented as frequency distribution, quantitative data as mean and standard deviation, chi square and correlation test were used Grades of correlation:

0.00-0.24(no or week), 0.25-0.49 (faire), 0.50-0.74(moderate), ≥0.75 (strong) P of less than 0.05 was considered as cutoff for significance

Results:                                                        

Table (1): Socio demographic data of the studied women:

Table (1) illustrate  that nearly half (49.7%) of pregnant women aged between 20-29 yrs., less than one third (28.7%) age 30-39yrs, about 19.3%  in category less than 20yrs, with the remaining 2.3%in category more than ≥40yr.  Also   more than half of studied women (52%) living in rural area, 77.7% of them were housewives. More over one third of studied women (33.7%) had secondary school and the majority of them (95.7%) had not enough income.

Table (2): Obstetric history of the pregnant women:

As regard to obstetric history table (2): show that more than half of the respondents (51.7%) in 2-3 pregnancies and more than one third in first pregnancy (33.7%) and nearly one third of them were nulliparous 101(33.7%) and nearly one third delivered from once to twice time previously (26%, 29%) and nearly 39.3% of them their gestational age were within 16wks -24wks.

Table (3): Subjective (self-assessed) assessment of oral health of pregnant women and Perceived causes of gum disease:

 (*caries in teeth - * Problems in stuffing teeth)

Table (3): demonstrate that the large proportion of the respondents (41%& 47.3%) reported that their dental and gum health during their pregnancy was good and healthy, less than one third (27%) their assessment their oral was very good,   also more than one third of the respondents (33.7%)   reported that they suffer from pain in oral cavity during pregnancy followed by hypersensitivity (22%) and bleeding (18.3%).   And their actions toward this problem were categorized as nearly half of them (49.3%) consulted the doctor. Some of them don’t examine their teeth (18%). Others don’t prefer medications (17.3%). And others go to natural recipes (15.3%).

Table (2): knowledge of pregnant women regarding oral health during pregnancy:            

Show that great about three quarter of pregnant women   (77.7%) did not know the importance of oral health, more than half of them had no information regarding methods to care of teeth (53.7%) and the response to Physiological changes that occurs in oral cavity during pregnancy also the majority of pregnant women (82.3%& 88.7%) had no any information related to oral Physiological changes during pregnancy and effect of Periodontal disease on pregnancy and fetal outcome

Ignorance of oral health and teeth, lake of intake of calcium during pregnancy and more intake of sugared and sweaty food were the most common causes of gum disease reported by the women (39.3%, 28.7% and 22.0%) respectively.

Table (4): Total score of Knowledge, attitude and practice regarding dental health among pregnant women:

This table illustrate that the mean ± SD of the total score of knowledge of studied women were (4.8±2.03) with large proportion of them (69.7%) had poor knowledge and about one third of them (30.3%) had good knowledge. Regarding the total score of attitude this table represented that the  mean ± SD of the total score of attitude was (6.1±2.4) and  more than half of them (55%)had positive attitude and about less than half (45%)with negative attitude. Also the mean± SD of the total score of practice was (5.2±3.1) with more than half of them (58%) with poor practice meanwhile 42% of them had good practice.

Table (5):  Attitude of pregnant women towards dental health:

Illustrate that large number of the respondents (69%) considered oral health should be a priority. Majority of the pregnant women (75.4%) agreed that she should have a dental checkup during pregnancy, (73%) oral health important component of primary health care. (69%) Pregnant women highly exposed to oral diseases,( 75.7%) pregnancy cause teeth loss, (87%) pregnancy cause calcium withdrawal, (67.3%)physiological changes that occur during pregnancy can affect the oral health and. meanwhile more than three quarter of studied women  (79.3%) disagree with gum disease can cause preterm labor.

Table (6): Oral health Practices followed by pregnant women:

Show that more than half of the respondents (52%) don’t brush their teeth during pregnancy, about one third of them (29.7%) brushing their teeth once daily .more than half of them (53%) spent less than 2 minutes in brushing their teeth. Nearly one third of them (30%) spent less than 1 minute in washing their teeth. Also more than one third of women (32%) using tooth brushing to washing their teeth, Less than one of them (29%) using of Toothbrush and past in washing teeth, less than one third of them (27.7%) rinsing their teeth with water .less than one third of them (28.3%) washing their teeth once daily before pregnancy. less than half of them (48.7%) don’t wash their teeth before pregnancy. Nearly half of them (49%) was changing their teeth brush every 3 months and more than one third of them (36.8%) changing their teeth brush every 6 months. 

Table (7): oral health Practices followed by pregnant women:

Less than half of the respondents (41%) washing their teeth before sleeping .more than one third of them (37.3%) washing after meal .almost of them (95.7%) don’t use any mouth wash during pregnancy. don't use any mouth wash before pregnancy (88.7%). More than three quarter (76.7%) of them don’t visit the dentist.  Meanwhile early three quarter of them (72.3%) don’t make dental checkup at primary health care.   Also more than half of them (51.3%) don’t visit the dentist when there was a problem in their teeth. And about (48.7%) visit the dentist when there was a problem.  More over Large number of them (66.3%) said that no one speak with them about dental care during pregnancy. And about (66.7%) don’t receive dietary advice during pregnancy. (21%) less than one third of them never seen a physician.   Most of them (64.3%) consult obstetric doctor about their oral health during pregnancy. 

Table (8): correlation of total oral health knowledge score and attitude of pregnant females:

*Significance difference.

Demonstrated that there were statistical significance difference between total knowledge score and total attitude and practices score (p= 0.001) respectively.

Table (7) the correlation between total score of knowledge /attitude / practices and socio-demographic data of the pregnant women:

* Significance difference.

Showed the correlation between total score of knowledge /attitude / practices and socio-demographic data of the pregnant women: The study show there was statistical significance difference  between  total knowledge score of the pregnant women and  their age ,level of education and  (p=0.007,0.01 and  0.01)  also regarding attitude the study reported that there was significance difference  between attitude of pregnant women and  their residence and level of education (p= 0.001&0.006).  More over statistical significance difference found between practice of the pregnant women and their occupation (p=0.001).

Table (9) the needed information of pregnant women regarding oral health:

Showed the needed information's of pregnant women about oral health most of them (48.3%) want to know the Importance of oral health. Some of them (16.3%) want Visual method about oral care. About (11%) of them want to know the Importance of Calcium intake and iron intake. Some of them (10%) want specialized units of oral health for pregnant women. Some (14.2%) want more Information about Relationship between oral health and pregnancy.

Figure 1:

Demonstrated that the barriers for seeking dental care. Most of the studied women (47.7%) considered high cost is the first barrier for seeking dental care during pregnancy followed by that 27.7% of them have no time lastly some of them (23%) were lazy for seeking dental care.