Factors Influencing the Provision of Oral Health Care Practices by Antenatal Care Providers: A Systematic Review

Abstract

Background:

Antenatal care (ANC) providers are recommended to promote oral health care during pregnancy through the provision of oral health care practices, but studies have indicated that providers remain unclear and inconstant in adopting these practices into routine care. Therefore, the objectives were to undertake a systematic review of the current oral health care practices of ANC providers and identify factors (barriers and facilitators) that influence the provision of ANC providers' oral health care practices.

Methods:

Qualitative and quantitative studies were systematically searched within four databases (database inception, October 2020). Studies were selected if they were published in English and conducted in developed countries. Thematic analysis was employed where reported barriers and facilitators from the included studies were grouped by themes and were inductively categorized within a multilevel framework. Reported current oral health care practices were deductively categorized according to a predetermined “assess,” “advise,” and “refer” framework. Summative frequencies of oral health care practices, if reported, were also extracted.

Results:

A total of 3519 ANC providers were included across 26 studies. Rates of reported current oral health care practices among ANC providers varied considerably. The most reported barriers related to providers' limited oral health care knowledge, concerns with dental costs, and absence of organizational referral processes. The most reported facilitators related to providers' level of oral health care knowledge, patient prompt, and access to informational and educational resources.

Conclusions:

Further efforts are needed to address the range of barriers identified in this review and support ANC providers' clinical practice behaviors. This includes improved interprofessional education, training opportunities, and integrated health care models.

Introduction

Improvements to oral health care, maternal health, and reduction of child mortality remain key global health targets in the Sustainable Development Goals for 2030.¹ Primary outcomes from cross-sectional and experimental research have provided evidence on an association between periodontal disease and risk of adverse pregnancy outcomes including gestational diabetes, preterm birth, low birth weight, preeclampsia, and perinatal mortality.² In addition, poor can contribute to diminished quality of life for pregnant women, and in the development of future early childhood caries of their children.³

Accordingly, antenatal care (ANC) providers are recognized as having a key role in the delivery of oral health care to pregnant women. Professional guidelines from the 2012 National Maternal and Oral Health Resource Center⁴ have sought to standardize oral health care practices and recommend ANC providers to assess pregnant women's oral health care status, advise on oral health care, and facilitate referrals to dental professionals. Many developed countries have adopted these oral health care practices into national professional guidelines and health care policies, which consistently encourage ANC providers to reinforce preventive health messages and assist pregnant women to make informed decisions regarding their oral health care.^5

–9

Despite this, studies have indicated that ANC providers remain unclear and inconstant in adopting oral health care practices into routine care.^10,11 This highlights that a potential gap exists between theory and clinical practice among ANC providers and posits an area for further exploration. Understanding current practice behaviors and factors that influence these could assist in the development of strategies to improve oral health care practices among ANC providers and identify areas requiring further research.

Few literature reviews have been conducted on the topic of oral health care practices by ANC providers and include reviews on the potential role of Australian midwives in oral health care promotion practices¹²; the barriers, knowledge, attitudes, and practice behaviors of ANC providers toward oral health care during pregnancy¹³; and the role of Indigenous health care workers in promoting oral health care to pregnant women.¹⁴ To date, no review has reported on the facilitators to ANC providers' oral health care practices. Thus, by building on the preceding work of these authors, the objectives of this review were to:

Identify evidence on the current oral health care practices of ANC providers; and,

Identify and synthesize factors (including barriers and facilitators) that influence ANC providers' oral health care practices in promoting oral health care during pregnancy.

Methods

We conducted a systematic review based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.¹⁵ Based on the design of this study as a systematic review, no Institutional Review Board (IRB) approval was required.

Terminology used

In this review, the term “antenatal care provider” will be used inclusively to describe the health care professionals who are primarily involved in women's ANC. This will include obstetricians, obstetrician-gynecologists (OBGYNs), medical doctors including general practitioners, and those who hold allopathic (MD) and osteopathic (DO) medical qualifications, nurses and nurse practitioners, midwives, Indigenous health care workers (including Aboriginal and Torres Strait Islander health care workers), and multicultural health care workers.

Search strategy

Systematic searches of four electronic databases were performed for studies published until October 1, 2020: MEDLINE via PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, and Scopus. The core search strategy was developed based on literature scoping ANC providers' oral health care practices to pregnant women. The search strategy (Supplementary Appendix SA1) consisted of joining MeSH terms and keywords to develop three concepts: “antenatal care providers,” “oral health practices,” and “pregnant women.” Reference lists of included studies and relevant systematic reviews were handsearched and screened to identify additional studies. No gray literature search was conducted.

Eligibility criteria

Studies were included if they met the following eligibility criteria: (1) participants: any or all ANC providers as previously described; (2) outcomes: barriers, and facilitators influencing oral health care practices to pregnant women from the perspective of any or all ANC providers; (3) design: qualitative, quantitative, and mixed-methods research; (4) language: published in English; and (5) country of origin: research conducted in any of the 37 Organization for Economic Co-operation and Development (OECD) member countries were selected.¹⁶ These OECD member countries (listed in Supplementary Appendix SA2) are regarded as developed countries because of their high Human Development Index and very high-income economies.¹⁶ Studies outside these parameters were excluded.

Study selection

Three reviewers (AW, HH and HB) independently screened the titles, abstracts, and full-text articles against the inclusion/exclusion criteria. Disagreements were resolved through discussion or fourth-reviewer consultation (LC).

Quality assessment

The methodological quality of the selected studies was assessed and scored using the Mixed Method Appraisal Tool (MMAT) by Hong et al.¹⁷ The methodological quality was assessed by one reviewer (AW) and checked by a second reviewer (HH) for accuracy. Any disagreements in assessments were resolved by discussion between reviewers or by third reviewer consultation (LC). No studies were excluded based on quality. Cutoff values were established through consensus among the authors, whereby studies with an MMAT score of 1 (of 5) were deemed low quality, studies with scores between 2 and 3 (of 5) were deemed moderate quality, whereas studies with scores of 4 and greater (of 5) were deemed high quality.

Data extraction and synthesis

The following data were independently extracted for each study by a single reviewer (AW) and checked for accuracy by (HH): country of origin, study aims, design, sample and study population, methods of analysis, and factors associated with providing oral health care practices. The associated factors were categorized into facilitators or barriers. Owing to heterogeneity in study outcomes and methodology, findings were synthesized thematically according to Braun and Clarke¹⁸ with similar findings inductively organized using a multilevel approach. These levels were found to be at the provider level, provider-perceived patient level, and organization level. Summative frequencies of oral health care practices, if reported, were extracted into a separate table. The oral health care practices, for the purpose of this review, were based on key recommendations of assessing oral health care status (verbal oral health care inquiry and visual oral examination), advising on oral health care (oral health care education), and referring to dental professionals (dental referrals).

Results

A total of 989 titles were retrieved from electronic searches in MEDLINE via PubMed (270), CINAHL (112), Embase (240), and Scopus (367). After removal of duplicates, 614 titles were screened. After title and abstract screen, 73 studies were considered for full-text review, of which 26 studies were included in the final review. The screening process with full-text studies excluded with reasons is given in Figure 1.

FIG. 1.

PRISMA flow diagram of included studies. OECD, Organization for Economic Co-operation and Development; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Characteristics and quality of included studies

Studies included in the review were published between 2007 and 2020, of which 12 were conducted in the United States,^{19

–30} 9 in Australia,^{31

–39} 2 in France,^40,41 and 1 each in Germany,⁴² Colombia,⁴³ and Canada.⁴⁴ This review included 14 quantitative studies,^{19,20,22
–24,28
–30,32,35,38,40,41,43} 8 qualitative studies,^{21,25,27,31,34,37,39,44} and 4 mixed-methods studies.^26,33,36,42 Nineteen of the studies were cross-sectional design,^{20
–22,24,25,27

–30,32,34,37

–44} followed by 6 experimental,^{23,26,31,33,35,36} and 1 secondary analysis from an existing national oral health care survey.¹⁹ Medical doctors (including general practitioners), nurses, nurse practitioners, midwives, obstetricians, and OBGYNs were represented across the 26 studies with a total study population of 3519. Midwives^{31,33

–38,42} and OBGYNs^22,23,41 were the two most frequently reported single-provider types across studies, with combinations of providers examined within 11 studies.^{20,21,24,25,27,29
–31,40,43,44} Overall, studies varied in methodological quality from low to high. The characteristics of included studies are summarized in Table 1, and the quality of included studies are given in Table 1 and Supplementary Appendix SA3.

Table 1.

Summary Characteristics of Studies Included in the Review

Study	Country	Study aims	Design sample size	Study population	Data collection	MMAT score
Adeniyi et al.⁴⁴	Canada	To explore the perceptions of providers on strategies for integrating oral health care	Cross-sectional	n = 11 midwives, nurses	Interviews	5
Boutigny et al.⁴⁰	France	To determine the oral health care knowledge, attitudes, and practices of providers	Cross-sectional	n = 11 OBGYNs, midwives	Questionnaire	1
Byrd et al.¹⁹	United States	To investigate the characteristics of primary care physicians regarding oral health care of pregnant women	Secondary analysis	n = 366 medical doctors^a	Survey data	5
Cohen et al.⁴¹	France	To determine the knowledge, attitudes, and practice behaviors of providers toward periodontal disease in pregnant women	Cross-sectional	n = 190 OBGYNs	Questionnaire	3
Corchuelo-Ojeda et al.⁴³	Colombia	To identify gaps in knowledge, attitudes, and beliefs toward oral health care in pregnancy among providers	Cross-sectional	n = 84 OBGYNs, GPs, nurses	Questionnaire	4
Dahlen et al.³¹	Australia	To evaluate and explore perceptions of midwives involved in the MIOH intervention	Experimental	n = 21 midwives	Focus groups	5
George et al.³²	Australia	To explore the knowledge, attitudes, and practices of providers and to identify barriers and enablers	Cross-sectional	n = 393 OBGYNs, GPs, midwives	Questionnaire	4
George et al.³³	Australia	To pilot the MIOH intervention	Experimental	n = 22 midwives	Education intervention	3
George et al.³⁴	Australia	To explore the perceptions of midwives on their role in promoting oral health care	Cross-sectional	n = 15 midwives	Focus groups	4
George et al.³⁵	Australia	To evaluate the effectiveness of the MIOH intervention	Experimental	n = 50 midwives	Questionnaire	5
Heilbrunn-Lang et al.³⁶	Australia	To explore the perspectives of providers in incorporating oral health care promotion following the MIOH intervention	Experimental	n = 33 midwives	Questionnaire	4
Hoerler et al.²⁰	United States	To determine the knowledge, attitudes, and practices of providers toward oral health care during pregnancy	Cross-sectional	n = 69 midwives, nurses, medical doctors	Questionnaire	2
Horowitz et al.²¹	United States	To determine the knowledge. practices and barriers of providers toward oral health care during pregnancy	Cross-sectional	n = 32 midwives, obstetricians	Interviews	5
Lim et al.³⁷	Australia	To explore facilitators to oral health care among providers	Cross-sectional	n = 12 midwives	Focus groups	4
Morgan et al.²²	United States	To determine the knowledge, attitudes, and practices of providers toward oral health care during pregnancy	Cross-sectional	n = 351 OBGYNs	Questionnaire	4
Nguyen et al.³⁸	Australia	To determine the knowledge, attitudes, and practices of providers toward oral health care	Cross-sectional	n = 100 midwives	Questionnaire	4
Riggs et al.³⁹	Australia	To explore the perspectives of providers toward oral health care of refugee pregnant women	Cross-sectional	n = 10 midwives	Focus groups	5
Shah et al.²³	United States	To evaluate the effectiveness of an oral health care education intervention among providers	Experimental	n = 25 OBGYNs	Questionnaire	3
Strafford et al.²⁴	United States	To compare the attitudes and perceptions of providers on oral health care during pregnancy	Cross-sectional	n = 249 obstetricians	Questionnaire	3
Vamos et al.²⁵	United States	To identify implementation science characteristics to inform the development of an e-health application	Cross-sectional	n = 4 midwives, nurses	Interviews	5
Vamos et al.²⁶	United States	To evaluate the effectiveness of an e-health application on providers' oral health care	Experimental	n = 4 midwives, nurses	Questionnaire Interviews	4
Vamos et al.²⁷	United States	To determine the oral health care knowledge, attitudes, and practices by providers	Cross-sectional	n = 11 medical doctors^a	Interviews	5
Wagner and Heinrich-Weltzien⁴²	Germany	To determine the oral health care knowledge and practices by providers	Cross-sectional	n = 947 midwives	Questionnaire	2
Wilder et al.²⁸	United States	To determine the knowledge and practices by providers toward oral health care outcomes	Cross-sectional	n = 55 obstetricians	Questionnaire	2
Wilson et al.²⁹	United States	To determine the attitudes and practices by providers toward oral health care during pregnancy	Cross-sectional	n = 146 OBGYNs, midwives	Questionnaire	3
Wooten et al.³⁰	United States	To determine the oral health care knowledge, attitudes, and practices among providers	Cross-sectional	n = 219 midwives, nurses	Questionnaire	3

Includes medical doctors who hold a allopathic (MD) or osteopathic (DO) qualification.

GP, general practitioner; MIOH, Midwifery Initiated Oral Health; MMAT, Mixed Method Appraisal Tool; OBGYN, obstetrician-gynecologist.

Current oral health care practices by ANC providers

Across studies, the main oral health care practices of verbal oral health inquiry, visual oral examination, oral health care education, and referral to dental professionals were reported.^{19

–22,24,27

–32,34,36,38,40
–42} However, the description and understanding of practices were often inconsistent. For example, in a study by Byrd et al.,¹⁹ most surveyed medical doctors agreed that they should be “able to identify signs of tooth decay, periodontal disease, oral malignancies, precancerous lesions, xerostomia, and Sjögren's syndrome.” In contrast, other studies considered the topic of oral health care more broadly or with minimal descriptors.^{25,37,39,43,44}

Frequency of oral health care practices varied, with a range of 0.5%–78.6% (Table 2) of ANC providers reporting always or almost always routinely adopting these practices into ANC.^{19,20,22,24,28
–30,32,36,38,40
–42} Frequency of specific oral health care practices included verbal oral health care inquiry (range: 5.8%–60.0%),^{20,22,24,29,32,38,41} visual oral examination (range: 1.0%–45.0%),^{20,22,24,28
–30,32,38,40,41} oral health care education (range: 8.0%–78.6%),^{19,22,29,32,36,38,41,42} and referral to dental professionals (range: 0.5%–70.6%)^{20,24,30,32,36,38,40,41} were reported. Similar findings across studies revealed that oral health care practices were influenced by whether the ANC provider believed the patient to be at risk.^{19,29,38,40,41} However, the term “at risk” was often poorly explained within studies, and no consistent criteria within the provision of oral health care practices by providers could be determined.

Table 2.

Frequency of Main Oral Health Care Practices by Providers

Study sample size	Oral health care practices
	Assess		Advise	Refer
	Verbal oral health inquiry	Visual oral examination	Oral health education	Dental referrals
Boutigny et al.,⁴⁰ n = 100^a	—	1.00%–5.00%	—	20.0%
Byrd et al.,¹⁹ n = 366	—	—	48.0%	—
Cohen et al.,⁴¹ n = 190^b	26.3%	24.9%	10.5%	33.2%
George et al.,³² n = 393^c	7.6%–14.9%	10.6%	7.3%–21.5%	0.5%–70.6%
Hoerler et al.,²⁰ n = 69^d	5.8%–10.1%	7.2%–8.7%	—	17.4%–21.7%
Heilbrunn-Lang et al.,³⁶ n = 33^e	—	9.1%	18.2%–24.2%	36.4%
Morgan et al.,²² n = 351	20.0%–23.0%	24.0%	8.0%–17.0%	—
Nguyen et al.,³⁸ n = 100^f	60.0%	7.0%	39.0%	49.0%
Strafford et al.,²⁴ n = 249	20.0%	29.0%	—	6.0%
Wagner and Heinrich-Weltzien,⁴² n = 947	—	—	53.5%–78.6%	—
Wilder et al.,²⁸ n = 55^g	—	9.0%–22.0%	—	—
Wilson et al.,²⁹ n = 146^h	35.0%	29.0%	42.0%	—
Wooten et al.,³⁰ n = 219ⁱ	—	3.0%–45.0%	—	40.0%–57.0%

Data based on criteria “Always” or “Often” in study questionnaire.

Data based on criterion “Systematic” in study questionnaire.

Data based on criterion “Always” in study questionnaire.

Data based on criteria “Always” or “Most of the time” in study questionnaire.

Data based on baseline (pretest) results before study intervention.

Data based on criterion “Routinely” in study questionnaire.

Data based on criteria “At initial visit” or “Periodically” in study questionnaire.

Data based on total sample (combined OBGYNs and midwives) in study questionnaire.

Data based on criteria “Strongly agree” and “Agree” in study questionnaire.

Factors influencing oral health care practices: facilitators and barriers

The following sections discuss the factors that influence oral health care practices by providers at the provider, provider-perceived patient, and organization levels. Summary of these factors are given in Table 3.

Table 3.

Factors Influencing Providers' Oral Health Care Practices

	Barriers	Facilitators
Provider level	Poor oral health knowledge^{20 –32,34,36 –39,42,43} Lack of individual self-efficacy^{19,21,22,25,26,28 –30,32,34,35,37} Unfavorable attitude to oral health care^{20 –24,27,29 –31,36,40,43,44} Lack of oral health care training and education^{21 –23,29,30,32,36,40,43,44} Lack of time^{20,21,25,26,32,33,37 –39,41,44} Poor collaboration with dentists^{21,24,25,29,39,43,44} Perceive oral health care as beyond clinical remit^{20,22,27,44,48} Competing professional demands^21,34,37,39 Perceived reluctance of dentists to treat^22,31,34,44 Perceived paucity of access to dental services^31,34,39,44 Poor clarity on role and responsibility for oral health care^24,25,38,43 Perceive oral health care as a “sensitive” or “uncomfortable” topic^21,34,43 Time intensiveness of intervention^25,26,33 Perceive oral health care as dentist's role^20,34 Medico-legal concerns³² Poor continuity of care³¹ Peer pressure from colleagues³² Professional protectionism⁴⁴	Level of oral health care knowledge^{19 –21,23 –26,28 –33,35,37,38,40 –43} Favorable attitudes toward oral health care^{19,20,22 –24,27,29 –32,35 –38,40,41,43} Oral health training and education^{19 –21,23,30,32,34,37,39,40,44} Level of individual self-efficacy^{24,26,27,29,30,35,36} Collaboration with dentists and integrated oral health care^24,25,30,44 Provide oral health care practices if patient considered “at risk”^38,40,41 Perceive oral health care within clinical remit^20,27,38 Midwife^22,29,32 and nurse²² qualifications More clinical experience^32,41 Female professional¹⁹ Time-intensiveness of intervention²⁵ Working in private practice⁴¹ Rural-based practice³⁸ Personal history of oral disease⁴¹ Continuity of care³¹ Clarity on role and responsibility for oral health care³⁶ Have “preferred” dentist²²
Provider-perceived patient level	Costs of dental treatment^32,33,37,44 Perceived disinterest from patients^{20,22,31,37,41} Poor level of oral health care knowledge^31,34,39,43 Lack of dental insurance^21,31,34 Misbeliefs toward oral health care and oral health care^31,32,37 Language and cultural discordance^37,39 Unfavorable attitudes toward oral health³⁷	Undertake oral health care practices if prompted by patient^{22,27,29,40,41} Level of oral health knowledge and favorable attitudes toward oral health^31,34,43 Educate patient on oral health if patient comorbid¹⁹ Visibly noted oral health complaint or problems²⁹
Organization level	Lack of dental referral protocols^20,31,34,37 Limited awareness of clinical practice guidelines^27,32,44 Absence of oral health policies and protocols^39,44 Lack of informational and educational resources⁴¹	Access to informational and educational resources^{21,25,26,32,34,37,39,44} Dental referral protocols^{22,25,31,37,39,44} Presence of oral health policies and protocols^27,37,44 Medical record prompts and intake systems that included oral health^21,25,27 Awareness of clinical practice guidelines^32,44 Subsidized dental care^34,44 Available list of area dentists^21,44 Co-location with dental services⁴⁴ Integration of patient health records⁴⁴

Provider-level factors

Across studies, several factors influenced oral health care practices at the provider level. A major influencing factor that impeded the provision of oral health care practices by providers was the lack of oral health care knowledge.^{20

–27,29
–31,34,36

–39,42,43} Conversely, ANC providers who were more knowledgeable in oral health care were reported as a facilitating factor to varied forms of oral health care practices.^{19
–21,23

–26,28

–32} Other frequently reported barriers across studies that impeded ANC providers' provision of oral health care practices included lack of time,^{20,21,25,26,32,33,37
–39,41,44} limited oral health care training and education,^{21
–23,29,30,32,36,40,42
–44} and competing professional demands.^21,34,37,39 Conversely, oral health care training and education were reported as a major facilitating factor to providers' practice behaviors, including oral health care inquiry, visual oral examination, oral health care education, and referral to dental professionals.^{19
–21,23,30,32,34,37,39,40,44}

Other studies focused on ANC provider attitudes and perceptions of practices related to oral health care.^{19

–25,27,29

–33,36
–38,40,41,43,44} These studies elicited several key provider-level factors: attitudes toward oral health care, level of self-efficacy, and sense of responsibility or role in oral health care practices. Low levels of these factors were associated with lower rates of varied forms of oral health care practices among ANC providers.^{19

–25,27

–32,34

–38,43} Conversely, favorable attitudes and good provider self-efficacy toward oral health care practices were reported as key facilitators and helped ANC providers to feel more comfortable in approaching and implementing oral health care practices.^{19,20,22

–25,27,29

–32,35

–38,40,41,43} Some exceptions included specific unfavorable attitudes about oral disease as a “sensitive” issue for patients,^21,34,43 perceived paucity of access to dental services,^31,34,39,44 or a perceived reluctance of dental professionals to treat pregnant women.^22,31,34,44 Of note, poor collaboration with dental professionals was reported as a barrier to ANC providers' comfort with oral health care practices within seven studies.^{21,24,25,29,39,43,44} Conversely, supportive collaboration with dental professionals facilitated ANC providers' oral health care assessment, education, and referral practices.^24,25,30,44

Six studies evaluated provider-level outcomes from interventions to improve the oral health care practices of providers.^{23,26,31,33,35,36} One intervention offered OBGYNs one training session provided by a dental professional, which demonstrated a significant effect on assessment and referral practices immediately postintervention, with a greater report of oral health care practices at 3 months postintervention.²³ In addition, four studies utilizing self-directed learning oral health care modules targeted at midwives found modest effects on attitudes, motivation, and comfort with introducing oral health care topics,^31,33,36 and one study reported significant improvement to midwives' oral health care knowledge and practices at 4 months postintervention.³⁵ Vamos et al.²⁶ observed the feasibility of an e-Health application on oral health care to midwives and nurses and presented feedback to practice immediately postintervention. Despite the training, few providers still demonstrated limited self-efficacy toward oral health care practices such as visual oral examination, documentation of findings, and providing oral health care advice.²⁶ In addition, some providers found the incorporation of these interventions time intensive.^26,33

Another influencing factor appeared to depend on provider qualification or specialty,^22,29,32 but overall findings were variable. For example, in a study by Wilson et al.²⁹ more midwives were found to discuss oral health care with pregnant women and recommended referral to dental professionals compared with OBGYNs. However, most studies reported minimal to no differences in practice behaviors among two or more differing disciplines^21,25,43,44 or did not distinguish between them.^20,26,30,40

The following facilitating factors to varied forms of oral health care practices were mentioned within a few studies: having more years of clinical experience^32,41; being a female professional¹⁹; working in private practice⁴¹ or rural-based area³⁸; having a personal history of experiencing oral disease⁴¹; and obtaining oral health care-related information from scientific publications.⁴¹ These facilitators were reported to improve ANC providers' frequency of current oral health care practices, and understanding of the need to include oral health care as a component of ANC. Limited awareness of clinical practice guidelines,^27,32,44 professional protectionism,⁴⁴ peer pressure from colleagues,³² having a “preferred” dentist,²² and concerns with medico-legal repercussions³² were additional barriers that impeded ANC providers' abilities to implement oral health care practices, particularly as it pertained to referral to dental professionals and oral assessment practices.

Provider-perceived patient-level factors

Several studies found provider-perceived patient factors as key influencers to on oral health care practices. Reported facilitators to providers' practices, particularly as it related to ANC providers willingness to undertake visual oral examinations, included, if prompted by patients or if patient had visibly noted oral concerns,^{22,27,29,40,41} or if patients had comorbidity.¹⁹ In particular, several barriers connected to the patient's personal attitudes and knowledge toward oral health care appeared to negatively influence the providers' willingness to provide overall oral health care practices.^{20,22,27,29,31,32,34,37,39
–41,43} For example, although good oral health care attitudes and knowledge were seen as facilitating factors to assessment and referral practices,^31,34,43 the patient's perceived lack of or limited knowledge of oral health care,^31,34,39,43 including perceived patient disinterest,^{20,22,31,37,41} entrenched misbeliefs surrounding oral disease and dental treatment,^31,32,37 and concerns regarding financial costs^32,34,37,44 were identified as barriers by ANC providers. The following impeding factors to varied forms of oral health care practices were mentioned in only a few studies: the presumed absence of a patient's dental insurance status^22,31,34 and language and cultural discordance.^37,39

Organization-level factors

At the organizational level, the absence or presence of policies and protocols for all forms of ANC providers' oral health care practices were key influencing factors.^{20
–22,31,32,34,37,44} Organizational protocols and policies for how to assess and manage oral disease (particularly as it related to introducing the topic of oral health care and referral of women to dental professionals) were cited as facilitating these practices. Specifically, the inclusion of referral pathways to dental services,^{22,25,31,37,39,44} availability and access to informational and educational resources (e.g., electronic medical prompts and intake forms that included an oral health care component, patient pamphlets, brochures, and waiting room posters),^{21,25
–27,32,34,37,39,44} and dissemination of clinical practice guidelines^32,44 were emphasized as crucial components. Absence of these factors were cited as barriers for ANC providers, resulting in providers feeling unprepared when confronted with concerns of oral disease.^{20,27,31,32,34,37,39,41,44} The following facilitating factors to all forms of oral health care practices were reported at the organization level within three studies: available list of area dental professionals,^21,44 subsidized dental service for patients,^34,44 co-location with dental services,⁴⁴ and medical-dental integrated patient health records.⁴⁴

Factors influencing specific oral health care practices

Factors influencing the provision of verbal oral health care inquiry, oral health care education, and referral to dental professionals were identified to occur across multiple levels with considerable overlap. However, a finding worth noting pertained to ANC providers' reservations to performing visual oral examinations.^{20,21,27,31,34,40} Specific barriers relating to this oral health care practice were found to relate to ANC providers' unfavorable attitudes toward oral health care, lack of oral health care training and education, and poor collaboration with dental professionals.^{20,21,27,28,30,31,34,38,40} In contrast, ANC providers who exhibited more favorable attitudes to oral health care had adequate oral health care knowledge and clinical experience, were prompted by patients and deemed collaboration with dental professionals as important often felt more comfortable in performing visual oral examinations, and reported providing this practice more frequently.^{20
–22,24,27

–31,34,40,41}

Discussion

The purpose of this review was to identify evidence on the current oral health care practices of ANC providers, and the factors that influence ANC providers' oral health care practices. Overall, we identified a myriad of barriers and facilitators to the provision of oral health care practices by ANC providers. Majority of influencing factors were found to occur at the provider level, but many were related to the provider-perceived patient and organization levels also. In addition, rates of oral health care practices among ANC providers varied considerably, suggesting that further efforts are needed to improve the clinical practice behaviors of ANC providers within oral health care.

The most predominant factor for both barriers and facilitators was the level of ANC providers' oral health care knowledge. A commonly reported barrier at the provider level was lack of oral health care knowledge that was closely related to ANC providers' lack of oral health care training and education. These findings are comparable with a previous systematic review by George et al.¹³ that identified limited oral health care knowledge and training as the largest barriers to ANC providers' oral health care practices. In contrast, several studies have described the positive effects of oral health care training on health care providers' knowledge and clinical practice behaviors including comfort toward implementing oral health care assessments, oral health care promotion, and referrals to dental services.^45
–47

Another important factor identified in this review was ANC providers' attitudes and beliefs regarding oral health care during pregnancy. Reported barriers in this review included unfavorable attitudes to oral health care and perceptions regarding women's oral health care experiences (including concerns with costs of dental treatment and perceived disinterest). Qualitative studies examining pregnant women's barriers to oral health care have reported congruent findings^10,48,49; yet, a desire for ANC providers to incorporate oral health care into antenatal visits is also reported.¹¹ Our findings and that of similar studies^49,50 show that ANC providers do not routinely discuss oral health care with pregnant women. This suggests the possibility that some of ANC providers' beliefs regarding oral health care during pregnancy may be misinformed and warrants consideration for providers to engage with pregnant women more actively.

Other barriers within this review included a lack of organizational support and referral processes. These findings align with international consensus on the need to integrate oral health care into primary health care.^51,52 Resources and organizational culture changes have been reported as necessary for successful integration of oral health care into health care.⁵³ Changes to organizational culture include a shift in infrastructure around supportive resources and training for all health care professionals and administrative staff on oral health care.⁵³ To illustrate, the use of integrated electronic health records may serve as a feasible strategy to integrate oral health care into ANC, but evidence pertaining to its effectiveness remains limited. Surveyed medical doctors have acknowledged that access to patients' oral health care information could positively impact their clinical decision-making,⁵⁴ whereas both medical and dental professionals have agreed that sharing of patient information between disciplines would improve quality of care, reinforce preventive health messages, and enhance referral processes.^54,55

Barriers and facilitators to specific oral health care practices among ANC providers were also identified. Practice behaviors as it related to verbal oral health care inquiry, oral health care education, and referral to dental professionals were found to occur across multiple levels with considerable overlap. This suggests that many of the barriers and facilitators to oral health care practices are commonly experienced by ANC providers and are relatively nonspecific. Of note, visual oral examination had the lowest reported rate within studies when compared with rates of verbal oral health care inquiry, oral health care education, and referral to dental professionals. Issues relating to individual self-efficacy, attitudes, knowledge and training, patient prompt and collaboration with dental professionals were found to provide some explanation for these variances. The availability of comprehensive training for ANC providers is likely needed to address these gaps in clinical practice behaviors and should seek to address factors at multiple levels within ANC. In particular, visual oral health care examination may require more concerted focus in training programs and require additional supports to ensure that ANC providers feel confident in implementing this practice routinely.

Thus, to address the reported barriers to ANC providers' provision of oral health care practices, there remains a need for formalized organizational support, continuing professional education and training opportunities, interprofessional education, and the development of evidence-based oral health care programs and implementation strategies. Education remains a logical starting point to address oral health care as clinical practice behaviors and attitudes toward professional identities are often siloed during this time.⁵⁶ Acknowledgement of specific training and educational requirements among the different ANC provider disciplines could provide information on when best to deliver education programs. Such programs should consider training at the undergraduate level as well as postgraduate and continuing professional opportunities and align with recommendations within clinical practice guidelines. The emergence of initiatives such as the Midwifery Initiated Oral Health (MIOH) program,⁵⁷ Prenatal Oral Health Program (pOHP),⁵⁸ Oral Health Nursing Education and Practice (OHNEP) program,⁵⁹ and Smiles for Life: A National Oral Health Curriculum ⁶⁰ could provide momentum to such considerations.

Strengths and limitations

The systematic literature search and transparent approach to evidence synthesis strengthened this review. However, there were some limitations worth noting. First, the validity of our findings could be limited as some potential biases and methodological issues were identified during the quality appraisal. Many of the studies used self-reported data that may introduce reporting biases that skew findings toward socially desired responses. In addition, more than two-thirds of quantitative data were at high risk of nonresponse bias because of participant attrition or inadequate follow-up.

Second, the generalizability of our findings could be intrinsically limited, as only studies published in English and conducted within developed countries were sought. This is further compounded by the fact that 12 of the 26 included studies were performed in the United States, and 4 of the 6 intervention studies were part of the same overarching project conducted in Australia (the MIOH education program).

Finally, although some small variations in oral health care practices were reported between midwives, nurses, general practitioners, and OBGYNs, no significant differences were demonstrated. Most studies either combined data to provide an overall description of oral health care practices and influencing factors to oral health care, or noted minimal changes between two or more disciplines. This suggests that some factors that influence the provision of oral health care may be shared among ANC providers. However, the heterogeneity in methodologies and a propensity for small sample sizes preclude our ability to confidently provide discipline-specific conclusions. We were also unable to perform a meta-analysis that could have further derived important associations. More robust studies that evaluate discipline-specific practice behaviors and influencing factors are needed. Such studies would also allow future researchers to compare practice behaviors across disciplines, evaluate areas of change, and develop necessary strategies to improve the oral health care of pregnant women and the oral health care practices of ANC providers.

Conclusions

ANC providers are well placed to promote oral health care to pregnant women in ANC, but their provision of recommended oral health care practices varies within the literature. Efforts to support interprofessional education, training opportunities, and integrated health care are necessary to address factors impacting ANC providers oral health care practices. Further research examining discipline-specific variation to practice behaviors and the development of effective implementation strategies across multiple levels of health care are needed to address barriers to ANC providers' oral health care practices.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

The authors received no specific funding for this work.

Supplementary Material

Supplementary Appendix SA1

Supplementary Appendix SA2

Supplementary Appendix SA3

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