Maintaining oral health during pregnancy: Perceptions of midwives in Southwest Sydney

Collegian (2011) 18, 71—79

available at www.sciencedirect.com

Maintaining oral health during pregnancy: Perceptions of midwives in Southwest Sydney Ajesh George, BDS, MPH, PhD a,∗, Maree Johnson, RN, B.App.Sci., M.App.Sci., PhD b, Margaret Duff, BN, PhD c, Anthony Blinkhorn, BDS, MSc, PhD d, Shilpi Ajwani, BDS, PhD e, Sameer Bhole, BDS, MDSc, FICD e, Sharon Ellis, RN, RM, MCN, BHSM f a

Centre for Applied Nursing Research (A Joint Venture of Sydney South West Area Health Service and the University of Western Sydney), University of Western Sydney, Locked Bag 7103, Liverpool BC, NSW 1871, Australia b Centre for Applied Nursing Research (A Joint Venture of Sydney South West Area Health Service and the University of Western Sydney), School of Nursing & Midwifery, College of Health & Science, University of Western Sydney, Australia c Centre for Applied Nursing Research, Sydney South West Area Health Service/University of Western Sydney, Locked Bag 7103, Liverpool BC, NSW 1871, Australia d Faculty of Dentistry, University of Sydney, 1 Mons Rd., Westmead, NSW 2145, Australia e SSWAHS Oral Health Services and Sydney Dental Hospital, Faculty of Dentistry, University of Sydney, Locked Mail Bag 7017, Liverpool BC, NSW 1871, Australia f Antenatal Services, Camden and Campbelltown Hospitals, Sydney South West Area Health Service, P.O. Box 149, Campbelltown, NSW 2560, Australia Received 8 April 2010; received in revised form 3 September 2010; accepted 20 October 2010

KEYWORDS Pregnancy; Oral health; Midwives; Prenatal care; Qualitative

Summary Current evidence highlights the importance of maintaining good oral health during pregnancy, unfortunately, many women in Australia do not access dental services at this time. Compounding the situation is the lack of importance placed on the value of good maternal oral health by prenatal care providers. These constraints highlight the potential value of having preventive oral health advice and referral to an appropriate care pathway during the prenatal period. Midwives are in an excellent position to offer such a service, although the specific aspects of the role have not been clearly defined in Australia. As a preliminary step to the development of an oral health service program, initiated by midwives, this study assesses the midwives’ perceptions of such an approach. Data were collected for this qualitative study via a focus group with 15 midwives. Thematic analyses of the data showed that despite the high prevalence of poor oral health in the area, most midwives were unaware of its possible

∗ Corresponding author at: Centre for Applied Nursing Research, Sydney South West Area Health Service, School of Nursing & Midwifery, University of Western Sydney, Liverpool BC, Locked Bag 7103, NSW 1871, Australia. Tel.: +61 2 9612 0672; fax: +61 2 9612 0676. E-mail address: [email protected] (A. George). 1322-7696/$ — see front matter © 2010 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.

doi:10.1016/j.colegn.2010.10.003

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A. George et al. ill-effects on maternal and child health. Midwives were also reluctant to discuss oral health with pregnant women because of a lack of appropriate referral pathways to the Public Dental Services. Midwives were receptive to the idea of establishing this new service but highlighted barriers such as the time involved, the competencies required and the need for referral pathways. The findings suggest that a midwifery-initiated oral health service has potential although issues such as training, time constraints and referral pathways must be addressed. © 2010 Royal College of Nursing, Australia. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.

Introduction There is growing evidence that poor oral health during pregnancy may have an impact on the health and well being of the mother and the baby. Research continues to show a strong association between poor maternal oral health and adverse pregnancy outcomes such as preterm deliveries, low birth weight babies and preeclampsia (Dasanayake, Gennaro, Hendrick-Munoz, & Chhun, 2008; Polyzos et al., 2009; Radnai et al., 2009; Xiong, Buekens, Fraser, Beck, & Offenbacher, 2006). Poor maternal oral health may also increase the risk of early childhood caries which is the single most common chronic childhood disease in the United States (Mills & Moses, 2002; Stevens, Iida, & Ingersoll, 2007). Studies show that the major mechanism by which children acquire bacteria causing tooth decay is through the direct transmission of infected saliva as a result of the mother having untreated caries, particularly if they engage in certain feeding practices (Berknowitz, 2003; Gussy, Waters, Walsh, & Kilpatrick, 2006; Yost & Li, 2008). Midwives have a major role in the perinatal care and are ideally placed to promote oral health for pregnant women and their infants (George, Johnson, Blinkhorn, & et al., 2010). This study examines what midwives understand about oral health in pregnancy and how they could enhance the oral health of pregnant women. Although debate continues over the causal link between poor oral health and adverse pregnancy outcomes, it is clear that providing dental treatment during the prenatal period does improve maternal oral health (Jeffcoat et al., 2003; Offenbacher et al., 2006). Several studies of periodontal treatment during pregnancy have shown significant improvement in the oral health status of mothers after therapy (Michalowicz et al., 2006; Newnham et al., 2009; Offenbacher et al., 2009). It is also evident that treating dental decay during pregnancy can significantly reduce the risk of infants developing early dental caries (Gussy et al., 2006). There is also no evidence to show that a dental examination or treatment is harmful to the pregnant woman or her developing foetus (Barber & Wilkins, 2002; Michalowicz et al., 2008). All these factors support the promotion of oral health during pregnancy. In recent years policy makers from various developed countries have acknowledged the concerns raised in the literature about the potential impact of poor maternal oral health. This has resulted in various preventive strategies being implemented during this period (American Academy of Pediatric Dentistry, 2009; National Health Service, 2008a). One of the main features of these strategies has been the engagement of non-dental professionals such as nurses and midwives in promoting oral health during pregnancy.

In the United States of America (USA), numerous national reports on oral health (U.S. Department of Health and Human Services, 2000, 2003) have highlighted the need for partnerships between dentists and other health professionals, including nurses and midwives. These recommendations have resulted in the development of evidence based practice guidelines (American Academy of Pediatric Dentistry, 2009; California Dental Association Foundation, American College of Obstetricians and Gynecologists, District IX, 2010; National Maternal and Child Oral Health Resource Center, 2008) for oral health care during pregnancy and early childhood for all health professionals including prenatal care providers. The most recent guideline (California Dental Association Foundation, American College of Obstetricians and Gynecologists, District IX, 2010) recommends that all pregnant women should receive a comprehensive oral health evaluation and risk assessment. Dental treatment is safe during pregnancy and this is the period when mothers need to be screened for oral risks, counseled on proper oral hygiene and receive necessary dental treatment. According to the guidelines, to achieve this goal non dental professionals such as midwives need to play an important role. Several studies support the need for prenatal care providers to promote oral health during pregnancy (George, Johnson, Blinkhorn, & et al., 2010; Lydon-Rochelle, Krakowiak, Hujoel, & Peters, 2004; Ressler-Maerlender, Krishna, & Robinson, 2005) and some prenatal care programs in USA already address oral health as part of standard practice (Carl, Roux, & Metacale, 2000; Stevens et al., 2007). In the United Kingdom (UK), all pregnant women are strongly advised by prenatal care providers to visit their dentist and seek treatment. Women are entitled to Maternity Exemption Certificates that allow them to receive free treatment with existing dental services under the National Health Service Scheme both during pregnancy and for the 12 months after giving birth (National Health Service, 2008a, 2008b; National Collaborating Centre for Women’s and Children’s Health, 2008). Unfortunately, Australia has not followed the example of other developed countries in addressing the oral health of pregnant women (George, Johnson, Blinkhorn, & et al., 2010). At present the initiatives to improve maternal and early childhood oral health such as the Early Childhood Oral Health (ECOH) program in New South Wales (NSW) focus solely on the postnatal period particularly on early interventions for children. Apart from written information and advice on oral health, the ECOH program does not evaluate the oral health of mothers during pregnancy (NSW Health, 2007). Even at the antenatal checks, which are often carried out by midwives, there is no evidence to indicate that adequate oral assessments are being conducted. This is probably

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due to the fact that the National Midwifery Guidelines for Consultation and Referral (2nd edition) do not provide any information or guidance about oral health during pregnancy (Australian College of Midwives, 2008). A recent systematic review of perinatal oral health has found that there is no system in place that can offer pregnant women in Australia regular oral assessments during the pregnancy or dental treatment at minimal cost (George, Johnson, Blinkhorn, & et al., 2010). The review also highlights that the unique potential of midwives to assess and improve the oral health of pregnant women is not being utilised. Compounding the issue in Australia, especially for pregnant women from low socioeconomic backgrounds, is the limited access to free public dental services and the high cost of private dental treatment (New South Wales Parliament, 2006). Currently, a preventive program to promote maternal oral health in Southwest Sydney is being developed and tested with the help of midwives (George & Johnson, 2009; George, Johnson, Ellis, & et al., 2010). Southwest Sydney has the largest and fastest growing populations in the State and is characterized by a high proportion of low socio-economic communities (Sydney South West Area Health Service, 2008) who, as a consequence, are at risk of poor oral health (Thomas, Middleton, & Crowther, 2008). The proposed midwifery initiated oral health (MIOH) program for Southwest Sydney involves midwives providing oral health education, assessment and referrals to pregnant women as part of standard midwifery care. However, numerous barriers have been cited that deter women from seeking dental care during pregnancy such as socioeconomic factors (U.S. Department of Health and Human Services, 2000); socio-cultural factors (Machuca, Khoshfeiz, Lacalle, Machuca, & Bullon, 1999); lack of resources to pay for treatment and barriers to access care (Boggess & Edelstein, 2006); lack of public awareness of the importance of oral health (Habashneh et al., 2005); and persistent myths about the effects of pregnancy on dental health, and, concerns for foetal safety during dental treatment (Wasylko, Matsui, Dykxhoorn, Rieder, & Weinberg, 1998). Unfortunately, most of the relevant research has been conducted in the USA and has mainly focussed on the views of pregnant women. Currently, no Australian studies have been published that explore the views of midwives regarding maternal oral health and the midwives’ potential in promoting oral health. The aim of this study was to explore the perceptions of midwives in Southwest Sydney about their role in terms of the practicability, acceptability and feasibility of a midwifery initiated oral health program.

Method

Research questions

Data analysis

• What do midwives in Southwest Sydney currently understand about the importance of oral health during pregnancy? • What are the barriers and facilitators to midwives in Southwest Sydney engaging in a midwifery initiated oral health program involving oral health assessment, health promotion and referral of women attending antenatal clinics? • What do midwives perceive as the barriers and facilitators that exist for pregnant women to participate in the midwifery initiated oral health program.

The digitally audio recorded data from the focus group were professionally transcribed. All transcripts were then imported by a research assistant into the computer software NVivo (NUD*IST Viv, 2003) to assist in coding and sorting segments of text. Thematic analysis (Van Manen, 1990) was undertaken and data was sorted into themes and sub themes that depicted the views of the midwives regarding oral health during pregnancy and various aspects of the proposed oral health service. The research assistant, a post-doctoral midwife and the chief investigator coded the transcript individually and through consensus the final list of themes and

Study design A qualitative approach involving a focus group of midwives from Southwest Sydney was used to answer the key research questions.

Setting The setting for this study was the antenatal clinic at a large metropolitan public hospital in Southwest Sydney. Ethics approval to conduct this study was granted by the Sydney South West Area Health Service Human Ethics Research Committee.

Sampling Purposive sampling was used to select participants for the focus group. Flyers advertising the study along with information sheets were distributed, via the midwifery managers, to all midwives working in the antenatal clinics. Interested midwives were asked to contact the project team for further information.

Data collection Using qualitative techniques, a focus group was conducted with midwives at a time and place suitable to all participants. The focus group was conducted by the project leader who was trained in qualitative techniques. Prior to the commencement of data collection, signed informed consent was obtained from all participants and brief demographic details were collected. The focus group lasted one hour and was recorded for analysis purposes. The focus group was conversational in nature, the flow of which was governed by the participants. Guidelines were developed to aid in the data collection and ensure that the interviewees were guided towards (but not restricted to) addressing relevant topics. The main key topics to be addressed were: the importance of maintaining oral health during pregnancy, barriers and facilitators to midwives undertaking the role of oral health promotion, assessment and referral, education and training skills required by midwives to undertake the assessments and barriers and facilitators in mothers engaging in midwifery-initiated oral health service in Southwest Sydney.

74 Table 1 Demographic participants.

A. George et al. details

Characteristics Age (years) 20—29 30—39 40—49 50+ Highest education qualification Graduate certificate Graduate diploma Bachelors degree Masters degree Midwifery experience (years) 1—9 10—19 20—29 30+

of

the

focus

group

Frequencies (n = 15) 4 1 6 4 4 2 6 3 2 3 6 1

Three participants were student midwives.

sub themes was formed (Lee, Mitchell, & Sablynski, 1999). This process added rigour to the analysis through peer coding.

Findings Fifteen participants consisting of 12 midwives and 3 midwifery students attended the midwifery focus group. The 3 midwifery students were aged 25 or less and were registered nurses (with bachelor’s degree and experience in antenatal care) who were completing their 1 year post graduate program to be registered midwives (Australian College of Midwives, 2010). The midwife participants ranged in age from 28 to over 50 years and had between 3 and 30 years of midwifery experience. Three of the participants had master’s degrees, six had bachelor’s degrees, four had graduate certificates and two had graduate diplomas. At the time of the study, participants worked in the antenatal clinics or wards, or as midwifery educators and consultants. The demographic details of the participants are explained in Table 1. The major themes that emerged from the midwifery group’s responses centred on their knowledge and experiences regarding oral health and pregnancy, their thoughts and concerns for the proposed service, issues about education requirements for the midwives conducting the oral assessment and potential barriers facing pregnant women engaging in the service.

Some midwives were aware of an association between low birth weight and poor oral health but others considered it reflected low socioeconomic conditions around diet and nutrition and different cultures. Another midwife, who had trained and worked in the UK, commented on how poor oral health, in particular dental decay, could affect the health of the infant: I remember during my training, we had to teach the patients about oral hygiene as well. Because when they’re pregnant they need that [education]. . . decay will affect the baby. Many of the midwives commented on the frequency of poor oral health care they had observed in women attending the antenatal clinic. One midwife stated she thought around one in every four women she saw had problems while other midwives considered it was more like one in every five women. The type of dental problems the women had ranged from decay, gingivitis, toothache, complaints of bleeding gums while others . . . don’t have any teeth. As one midwife explained, many of the women . . . that have no teeth are also on the methadone programme, have been drug addicts and they’ve lost them during the course of their life experiences and they can’t afford to get them fixed so they deal with what they’ve got. The midwife added that the women might say . . . I’m off the ‘gear’ now but, you know, this is the end result . . . [of taking drugs]. These comments highlight the sensitive nature of oral health for some women. Although the midwives identified that they currently have an oral health section on the antenatal check list they do not ask specific questions One midwife stated that she asks women if they have anything wrong with their mouth and if they say ‘yes’ she tells them to see a dentist. Other midwives observed I think it’s obvious when you’re looking at someone’s teeth. . . that they have a problem but. . . it’s just hard to bring it up because it’s sensitive. This issue of sensitivity was highlighted by another midwife who observed: Sometimes you don’t want to broach it because you’re embarrassed for her. Saying she’s got no teeth and you’re looking at her and you’re thinking what can I do for her and you’re thinking I’m probably going to embarrass her if I say when was the last time you went to the dentist. In addition to the sensitive nature of asking oral health questions, another issue for midwives was how to help pregnant women if they have oral problems without having proper referral pathways. A few midwives pointed out:. . . if you can’t offer them a solution, how do we deal with that? How do we support that? If the waiting list (to access free public dental services) is going to be six weeks, like, what’s the point. You need to be able to get them in and be seen ASAP.

Perceptions about assessing women’s oral health Knowledge and experiences regarding oral health and pregnancy Few of the participants had knowledge about a link between poor oral health and pregnancy and infant outcomes. As one midwife, who was an educator, stated: I knew there were some studies that had been done on oral health and . . . maybe linking it with prematurity.

There was considerable discussion around the idea of midwives assessing women’s oral health. Some considered that it was a dentist’s role (. . .we are not dentists. . .) while others thought they did not have the time (. . .that would be a time consuming thing) or the skills. Midwives currently have one hour in which to complete a booking visit. This includes asking oral health questions although these were non-specific questions asked in diverse ways by different midwives. As

Maintaining oral health during pregnancy one midwife explained: . . .You ask them if they’ve got any problems with their mouth. . . . I don’t go into bleeding gums, tooth activities. If they say yes, you ask them what problems, and you should go and see your dentist. Another added that she asks only about their teeth and dental care. One midwife commented: It would be good I think to have specific questions so that we all ask the same questions. Asking questions about women’s oral health was one thing. The suggestion that midwives could then assess a woman’s problem if identified was another. Some participants were concerned that they would need to lift the woman’s lip to complete an assessment. . .so are we going to lift the lip? . . . Can’t they do it themselves? However after some discussion, the midwives considered they could do an assessment if it was only on the women who identified they had a problem and agreed to being assessed. As one midwife stated you only need to ask the questions and wait for the woman’s answer. If you need to assess: You’re confirming their concerns and you’re acknowledging that, yes, you have got red gums or you have got a hole in your tooth. You’d better go and see a dentist. That’s all it is. It’s confirming it. Despite a few reservations about assessing pregnant women’s oral health most midwives acknowledged the potential benefits of this new service and the value of their role. As one midwife noted: It’s another thing that we’re going to have to ask and it’s taking away from the other things that we as midwives want to talk to them about. However, this is about their family and it’s about the baby, which is part of our role I guess too.

Education requirements of midwives providing the service There was much discussion from the midwives around this theme. The majority of midwives however indicated they would be interested in completing a specific education program and learning the skills required to assess oral health. The issues that emerged from this theme included suitable blocks of education time, which days would be suitable and the length of the training period and form of competency assessment. Most agreed that they needed to be competent in an oral assessment and be assessed by someone who was competent themselves. Suggestions on the mode of education included attending education sessions . . . a couple of weeks in a row or if we had enough notice then a two hour session. One midwife thought that the education sessions could include . . .some case reviews, like seeing a woman’s journey if nothing happened or a scenario this is what could happen to you. While a different midwife suggested that the researchers could . . . book another one of these. . . sessions . . . while we’re here with some mannequins, dummies, pretend teeth, whatever you do, just so we have a visualisation of what you expect us to look at. Another midwife suggested I’d like information before I came to an education session, to read about it before we came. . . and some suggested that this could be provided by the internet or email and it did not need to be in hard copy.

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Barriers facing pregnant women engaging in the proposed service The midwives highlighted what they thought might be issues for women being referred for dental treatment during pregnancy. They agreed that it should be free as dental care is very expensive. As one remarked . . . for a regular check up . . . with nothing wrong, costs a lot of money. But as a number of other midwives commented If you don’t have private health insurance you’re out of pocket. . . and . . . even if you do have private insurance you only get forty percent back . . .and therefore there is . . . no incentive for people to maintain their oral hygiene. Another issue raised was the apparent confusion among dental professionals about the safety of undertaking dental treatment during pregnancy. As one midwife commented: I had one lady who wanted to have the rest of her teeth removed because she’d lost a lot of her teeth . . . her dentist had to get a letter from us to say it was safe to remove the rest of her teeth and get the dentures. The doctors then here decided she had to wait until she was post 28 weeks to have the rest of her teeth removed. So there seems to be a, I don’t know, a confused understanding of what is safe and what isn’t safe. There was also debate about where and when a free dental service should be held. Suggestions included the local community centre, other community areas where there is no dental service currently and the hospital. As one midwife noted it has . . . to be on a bus route or the nearest station for everyone to access. Which day of the week it should be held was also discussed. Some considered it would depend on if women had children at school, if they worked or had commitments at the weekend. Even the time of day was an issue as one midwife noted . . . A lot of the women don’t even want to come to the clinic in the afternoon because they have children. . . at school. One midwife suggested the hospital as the best place to hold the free dental service . . . If it was here it would be good, they could . . . go for their clinic appointment or something at the same time. Part of the plan for implementing the new service was to include education for the women. The midwives suggested that a . . . pamphlet on oral hygiene in pregnancy. . . which they could give out to women would be ideal. As another commented, a pamphlet would back up and reinforce the information midwives already give but it needed to be brief, perhaps ‘Question and Answer’ style. As one midwife remarked, the women ask . . . is it safe for me to have gas when I go to the dentist or is it safe for me to have the nerve block? So this style of education would be great. All midwives felt that women would be happy to receive oral health promotional material. The suggestion that a referral pathway would be included in their information also appealed to the midwives.

Discussion This study sought to explore the potential for midwives in Southwest Sydney to engage in an oral health program providing oral health education, assessment and referrals for pregnant women attending the local antenatal clinic. Preg-

76 nant women in Southwest Sydney are likely to have higher rates of poor oral health than the average population due to the increased number of low socioeconomic communities in the area (Sydney South West Area Health Service, 2008; Thomas et al., 2008). Findings from the study confirm this view with a number of midwives commenting on the frequency of poor maternal oral health encountered in the antenatal clinics. The prevalence of poor oral health in this area is probably why oral health has been included in the antenatal checklist in this particular hospital, despite being absent from the National Midwifery guidelines. The need to address oral health during antenatal care is clearly supported by new evidence based oral health guidelines (California Dental Association Foundation, American College of Obstetricians and Gynecologists, District IX, 2010) However, the findings suggest that very few midwives in Southwest Sydney comprehensively address oral health with their clients. One of the main reasons attributed for this was the lack of clear referral pathways for pregnant women needing dental treatment. Midwives were aware of the lack of dental services to cater for these patients and therefore felt it was pointless pursuing the issue of oral health further. Another reason was that midwives felt that exploring oral health was a sensitive issue that could potentially embarrass the pregnant woman. The issue of sensitivity among pregnant women regarding oral health is an interesting finding which has not been cited as a potential barrier in the literature. Considering the nature of the discussions that pregnant women have with midwives regarding their pregnancy and general health it seems reasonable that they would be comfortable disclosing their oral health problems. The findings also illustrate that many midwives are unaware of the importance of maintaining oral health during pregnancy. Only a handful of midwives knew about the potential impact of poor maternal oral health on the health outcomes of the mother and child. This lack of knowledge could be an added reason why midwives have not really stressed the importance of oral health during antenatal visits. Considering the numerous other assessments midwives need to complete with pregnant women, it is easy to understand why oral health can often be overlooked during the antenatal visits. Despite raising concerns most midwives were willing to take an active role in promoting oral health during pregnancy. Most were receptive to the idea of incorporating oral assessments into standard midwifery practice and welcomed the idea of asking specific dental questions as recommended by practice guidelines internationally (National Maternal and Child Oral Health Resource Center, 2008). It is apparent that because of the lack of guidelines on oral health in Australia, midwives are currently addressing this topic in diverse ways which may not be beneficial to the patient. It is important to note that they were also open to the idea of visually inspecting the oral cavity, if required, to complete the oral assessments. Visual inspection of the oral cavity has been an integral part of other prenatal oral health programs internationally involving midwives (Carl et al., 2000). Although conducting visual inspections of the oral cavity may not, in some cases, provide additional information, the findings suggest that undertaking this additional task will assist in confirming any issues raised and indirectly reinforce the importance of oral health among pregnant

A. George et al. women. Visual inspection could also assist midwives identify other dental problems that pregnant women might be neglecting or unaware of. This could be beneficial considering pregnant women often perceive that poor oral health during pregnancy is normal (Ressler-Maerlender et al., 2005; Stevens et al., 2007). In order for midwives to undertake this new service effectively it is clear that a number of barriers need to be addressed. The concept of using non dental professionals such as prenatal care providers to conduct oral assessments is a contemporary development (National Maternal and Child Oral health Resource Center, 2008) and as such, prior to this study there has been no evidence to illustrate potential barriers. The findings have provided a valuable insight into this unexplored area. One of the key issues emerging is the midwives’ lack of knowledge and skills in conducting oral assessments. Midwives wanted appropriate education and training to be provided to ensure their competence in assessing the oral health of pregnant women. The strong emphasis on education could be attributed to the fact that if midwives are to conduct visual inspections as part of the oral assessment they need to be aware of both normal and abnormal features of the oral cavity. This is especially important considering most midwives in Australia have not been given any basic knowledge or guidance on perinatal oral health during their training (George, Johnson, Blinkhorn, & et al., 2010). Another potential barrier is time constraints. The study findings indicate that at the first antenatal appointment (booking visit) midwives have one hour to complete a series of risk assessments with pregnant women and as such have limited time to conduct other assessments. In light of these findings it is important that the proposed oral assessment should be of short duration. However, the issue of time constraints did not feature as prominently in the findings as would be expected. This is possibly because midwives at the study site already had oral health included on their antenatal check list and hence did not view the additional specific dental questions as substantially more time consuming. Nevertheless, it is still very important to consider time constraints when implementing oral assessments into standard midwifery practice. The findings also confirm previously cited barriers that could deter pregnant women from accessing dental services during pregnancy, such as the high cost of dental treatment (Habashneh et al., 2005; Mangskau & Arrindel, 1996) concerns among mothers about the safety of dental treatment during pregnancy (Wasylko et al., 1998) and confusion among health professionals including dentists about dental treatment during pregnancy (Shrout, Comer, Powell, & McCoy, 1992). Although a number of studies (Gaffield, Colley, Malvitz, & Romaguera, 2001; Habashneh et al., 2005; Mangskau & Arrindel, 1996) show that pregnant women with private health insurance are more likely to access dental services, our findings suggest that some pregnant women in Australia, especially those from low socio economic communities, may still be reluctant to seek dental treatment due to the high costs or lack of access to free public dental health services. It is clear that in order to ensure pregnant women engage in the proposed new oral health service it is critical to address the barriers identified. As pregnant women in Southwest Sydney are likely to have low socioeconomic

Maintaining oral health during pregnancy backgrounds and therefore a higher risk of suffering poor oral health (Sydney South West Area Health Service, 2008; Thomas et al., 2008), they should have priority access to free dental services, which should be easily accessed by public transport and should have operating hours that are suitable for pregnant women with school going children. The provision of free dental treatment to pregnant women already exists in other developed countries such as UK (National Collaborating Centre for Women’s and Children’s Health, 2008) and Greece (Dinas et al., 2007). Lastly pregnant women should be provided with detailed advice about all aspects of oral health during pregnancy, as such information could help alleviate the concerns of pregnant women about the safety of dental treatment. It is essential that all health professionals including dentists must be made aware of the latest perinatal oral health guidelines to ensure that there is no confusion or concerns regarding dental care during pregnancy. In summary, this study supports the need for a comprehensive intervention program to improve the oral health of pregnant women in Southwest Sydney. The prevalence of poor maternal oral health in the area, the lack of awareness about the importance of oral health coupled with the limited access to dental services all highlights this need. An oral health service program initiated by midwives is a potential intervention program that could be well received in the area if it is tailored to the needs of the population. Such an approach, though new in Australia, is being followed in other countries (Carl et al., 2000; Stevens et al., 2007) and is clearly supported by current guidelines (National Maternal and Child Oral Health Resource Center, 2008) and literature which emphasise the need to address oral care in prenatal programs (Lydon-Rochelle et al., 2004; Ressler-Maerlender et al., 2005). This study represents a qualitative study of a small number of midwives and therefore the findings are not generalisable. However, a Randomised Control Trial is underway to test the various components of the program (visual inspection, duration, etc.) and evaluate its effectiveness in promoting and improving maternal oral health (George, Johnson, Ellis, & et al., 2010). The proposed oral health program, if effective, will offer midwives a unique role in improving and maintaining the oral health of pregnant women and infants in Australia.

Implications As more countries acknowledge the potential role of non dental professionals in improving perinatal oral health it is important to consider the implications. For example, midwives are in an ideal position to improve maternal and infant oral health at the clinical level since they work with women within a primary health care framework and their role includes health promotion (Australian Nurses and Midwives Council, 2006). Midwives already screen women during pregnancy for a variety of sensitive issues including alcohol and drug abuse, family violence (Mollart, Newing, & Foureur, 2009) and smoking cessation (Ebert, Van der Riet, & Fahy, 2009). Where the service is available they also refer the women for professional therapy, counseling and support. It would appear appropriate therefore, that midwives extend their role to include the promotion

77 of oral health during childbirth and to screen and refer women to dental services for diagnosis and treatment as appropriate. It is not surprising that many midwives in this study were unaware of the importance of monitoring oral health in pregnancy as the topic is not included in any National Australian Guidelines (dental or midwifery) or pre-registration education programs. This requires urgent attention as International guidelines now strongly recommend all prenatal care providers to include oral assessments as part of standard prenatal care (California Dental Association Foundation, American College of Obstetricians and Gynecologists, District IX, 2010). The MIOH program if found effective in improving maternal oral health will further support the need to incorporate oral health into current midwifery guidelines in Australia. In addition, a post registration education program, to assist midwives in their practice, should be developed and included in MidPLUS which is an online National Continuing Professional Development program offered through the Australian College of Midwives (Monaghan & Shorten, 2008). Both pre and post registration education programs need to address the background literature on oral health in pregnancy and infant health and issues of health promotion, how midwives can sensitively discuss with women oral health issues, how to inspect the woman’s oral cavity if necessary to confirm a problem, and how and where to refer appropriately. Some midwives indicated that they felt oral health was a sensitive issue and that the women would be embarrassed about broaching the topic. However, midwives have had to learn strategies for asking difficult questions about such issues as drug abuse. Trust within the midwifery relationship is one of these strategies so that women will disclose difficult issues, such as family abuse, to midwives (Lauti & Miller, 2008). Developing an education program that builds a midwife’s confidence in handling different scenarios related to difficult or poor visual oral health would help.

Conclusions Midwives play a pivotal role in influencing pregnant women about all health matters for themselves and their unborn infant. A precise definition of the scope of midwives role in oral assessment—–asking valid questions relating to oral health in a consistent manner and undertaking a preliminary oral assessment—–has been acknowledged by a group of midwives in Southwest Sydney. These midwives have also clearly articulated their educational needs and an appropriate education program is nearing completion. Larger studies are being undertaken to evaluate the midwifery initiated oral health program and assess its effectiveness in promoting and improving oral health among pregnant women (George, Johnson, Ellis, & et al., 2010). The comprehensive nature of the health care aspects covered within the women’s initial visit to the antenatal clinic will continue to challenge midwives’ ability to support oral health promotion during pregnancy. The availability of a free dental service for women attending the clinic does provide an incentive (or the removal of a barrier) for midwives to encourage women to improve their oral health and the health of their children.

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Acknowledgements Funding to undertake this study is gratefully acknowledged from the Australian Dental Association (NSW) and The Centre for Oral Health Strategy (NSW).

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