Pregnancy is associated with a variety of hormonal and physiological changes that affects all body organs, including the oral cavity. ¹ During pregnancy, due to the increased appetite for eating sweets, increased oral acidity, and increased estrogen and progesterone secretion in women, they are more prone to dental caries ² , ³ , ⁴ , ⁵ (up to 75% of pregnancies) ⁶ which can lead to periodontitis. ⁷

Fear, anxiety, economic problems, and lack of information on oral health during pregnancy are the factors that prevent pregnant women from receiving dental care services. Furthermore, some studies have shown ⁸ that even many physicians recommend pregnant women to postpone receiving dental care until the postpartum period. These misconceptions can reduce the quality of life of pregnant mothers due to the lack of the treatment of oral and dental diseases and may lead to the transmission of infection to the offspring and will have negative effects on the mother and the child, even after childbirth. ² , ⁹ , ¹⁰ , ¹¹

Hormonal and immunological changes in pregnant women may lead to periodontal diseases, which, if left untreated, can lead to preterm delivery, and low birth weight. ⁹ , ¹² , ¹³ Periodontal in adults is also associated with cardiovascular diseases and pulmonary infections.

Both the American College of Obstetricians and Gynecologists and the American Academy of Periodontology recommend that “Pregnant women and those who are getting prepared for pregnancy should undergo periodontal examinations.” ¹ , ⁹ Several dental guidelines also emphasize that dental care and related education should be considered as part of prenatal care, and pregnant women should receive these services during pregnancy, participants such as oral health and the effectiveness of fissure sealants on the prevention of caries. ⁹ , ¹⁴

Having dental insurance and high education can improve the use of dental services. ⁴ However, a lack of tendency to receive oral and dental services during pregnancy has always seen among all groups of people, even those with high education and high-income levels. ⁹ , ¹⁵

Studies in the United States and Australia showed that the use of dental services by pregnant women was lower than 50% and 36%, respectively. ¹⁶ Furthermore, little is known about the prevalence and associations of not receiving dental care during pregnancy in Iran. ¹⁷

A better understanding of the factors that affect the utilization of dental care by pregnant women would be immensely useful to develop new initiatives aimed at increasing access to and use of dental care by women during pregnancy. Hence, the aim of this study was to investigate the prevalence of and the factors related to not receiving dental care during pregnancy in Iran.

This population-based study was conducted on 4071 mothers in 10 provinces of Iran, namely Fars, Yazd, Golestan, Hormozgan, Khorasan Razavi, Southern Khorasan, Hamadan, Kermanshah, Charmahal-O-Bakhtiari, and Kohgiloyue-Buyerahmad Figure 1. Figure 1

Study project location in Iran.

Of all women in the sample, 54.70% were reported not received dental care during pregnancy. In mothers who had a history of stillbirth, neonatal death and live birth, the prevalence of not receipt dental care during pregnancy were 54.56%, 48.92%, and 58.76%, respectively. As shown in Table 1, there is a significant difference for dental care (χ ²= 25.45, P < 0.001) between the three groups. Table 1presents an overview of dental care during pregnancy.{Table 1}

What stands out in Table 2is the majority of women in the sample was aged 24 years or older and had experienced at least one birth before the index pregnancy. More than half of the sample was Fars ethnicity. Almost 36.10% of the sample had graduated from high school (10–12 years education), whereas another 10.80% were college graduates. More than half were rural live (54.50%). Ninety percent of the sample was housewife, 36.80% was in the first pregnancy, and 90% reported an intended pregnancy. A relatively small percentage of women (4.70%) reported smoking at any point during pregnancy.{Table 2}

Table 3displays the results of the unadjusted logistic regression models predicting the lack of receipt of dental care during pregnancy in the study (with Pseudo R ²= 3.5%). The odds ratios (ORs) for mothers more than 35 old years than to 15–24 years for the lack of dental care during pregnancy were 1.41 (95% CI 1.14–1.75). Compared with parity mothers, mothers multiparous had higher odds of not receiving dental care (ORs ranging from 1.33 [95% CI 1.16–1.52] to 1.37 [95% CI 1.12–1.66]). The risks of not receiving dental care during pregnancy were lower among mothers in racial/ethnic minority groups. For example, the ORs for the lack of dental care during pregnancy ranged from 0.21 (95% CI 0.15–0.29) for Lurs to 0.23 (95% CI 0.19–0.28) for Turkic relative to Fars mothers. Lacking a pregnancy intention (OR = 1.35 [95% CI 1.09–1.66]) also were associated with a lack of dental care during pregnancy.{Table 3}

In the multiple logistic models, the study found that rural condition has 1.68 times the impact on not receiving dental care during pregnancy. The association between ethnicity and not receiving dental care is interesting because the risks of not receiving dental care during pregnancy were lower among women in racial/ethnic minority groups (Lurs) (OR = 0.21 95% CI 0.15, 0.29 for Lurs ethnic and OR = 0.22 95% CI 0.18–0.27 for Turkic). As shown in Table 4, there is a significant association between the not intended pregnancy and not receiving dental care during pregnancy. The details results of the association analysis are set out in Table 4.{Table 4}

This work has revealed several factors that are associated with not receiving dental care during pregnancy in mothers with a history of stillbirth, neonatal death, and live birth in separately. Ethnicity and place live of mothers are key factors in all groups [Supplementary Table 1[SUPPORTING:1]] and [Supplementary Table 2[SUPPORTING:2]].

The results of the present study indicated that in the 10 investigated provinces more than half of the pregnant women do not receive dental care. According to the conducted studies, the prevalence of not receiving dental care in pregnant women in the United States is 30%, Australia 50%, and in Latin America, Africa, and Asia 66.5%–75.5%, ²⁰ which in general indicates that the difference in the prevalence of not receiving dental care by pregnant mothers is influenced by the development and socioeconomic conditions of the countries. The results of the study by Bayat et al. in Hamedan, consistent with the results of this study, indicated that half of pregnant women had not referred to the dentist during their recent pregnancies. ¹⁷ Consistent with the results of our study, Lydon-Rochelle et al. reported that 58% of pregnant women did not receive dental care during pregnancy. ²¹ In the study by Marchi et al., 65.5% of pregnant women and 62% of pregnant women who reported a dental problem had not received any dental care during pregnancy (1) In the study by Singhal et al., less than half of pregnant women (48%) reported dental visits during pregnancy. ²² Low level of awareness and misinformation about oral health during pregnancy can be one of the reasons for low level of receiving dental care during pregnancy, as the study by Haji Kazemi et al. indicated that only 5.6% of pregnant women have good knowledge of oral and dental care during pregnancy. ²³ Screening and referral of oral and dental problems during pregnancy have significant importance, and pregnant women should receive preventive care in addition to healthcare during this period. ⁹ The lack of attention to oral health in pregnant women is primarily due to the risk of the birth of a preterm neonate, and also relates to diseases such as diabetes, cardiovascular, and respiratory diseases. ¹⁷

The results of this study indicated the relationship between parity and dental care, as the lack of dental care in women in the second-to-fourth parity was 1.37 times of the women with first birth, which was similar to the results of the study by Ojeda. ²⁰ Contrary to the results of the present study, in the study by Dinas et al., the usage rate of dental care in pregnant women was lower in women with the first and second pregnancy than in the third pregnancy, and this difference was statistically significant. ¹ In the study by Marchi et al. ⁹ as well as the study by Al Habashneh et al., ²⁴ no statistically significant relation was observed between parity and not receiving dental care. The reason for lower dental care in the second-to-fourth parity compared to the first parity can be on the one hand because of the high sensitivity of the pregnant mother in the first pregnancy compared to the subsequent pregnancies so that the pregnant mother can perform prenatal care more regularly in first parity. Second, it may be stressful that the dental environment and the lack of need experienced in the first parity may be the reason for not coming to the second parity.

In this study, the residence location has a statistically significant relation with receiving dental care. The lack of receiving dental care in rural areas is 1.68 times higher than in urban areas. In contrast to the results of this study, the results of the study by Mital indicated that residents in rural areas were directly related to receiving dental care, and the chance of receiving care in the village was 1.82 in comparison to the city. ²⁵ Low level of receiving dental care in rural areas can be due to the lack of awareness about the importance of oral hygiene and its adverse effects on the pregnant mother and the fetus, the unreachability of the dentist in the villages and the wrong beliefs that lead to less referral for receiving dentistry services. On the other hand, access to dental care is directly related to economic status. ²⁵

Our study indicated that unplanned pregnancy (compared with planned pregnancy) is a risk factor for not receiving dental care in pregnant women, that is consistent with the results of the study by Umer et al. ²⁶ In Marchi et al., ⁹ there was a meaningful association in unadjusted logistic regression between unplanned pregnancy and not receiving dental care in pregnant women, but this association was not observed in the unadjusted model. Mothers with unplanned pregnancy may not be physically, psychologically, or even economically ready for pregnancy, and this can be effective in their willingness and desire to receive dental care. ²⁷

The results of the present study indicated that there is a difference between the ethnic groups in receiving dental services, which is not consistent with the results of the study by Al Habashneh et al. ²⁴ On the contrary to the results of some studies in which racial and ethnic differences are identified as the factors of the lack of access to dental services in mothers during pregnancy, ⁹ , ²⁸ it seems that in our country, Iran, the ethnic and racial differences are not the main reason for not having access to a variety of health services at different levels in the health system. The difference in receiving services by pregnant mothers in this study, more than the result of ethnic differences, is due to factors such as socioeconomic factors, behavioral factors, and demographic factors. This is somewhat evident in this study by the low level of receiving dental care in rural areas than in urban areas. ²⁹ , ³⁰

It is necessary to note that according to the results of several studies, ¹⁷ another important influencing factor on pregnant women to refer and receive dental services is the knowledge and awareness of mothers and the perceiving the benefits and safety of using of dental services during pregnancy; ²⁴ therefore, providers of birth services or primary care, including health-care providers, nurses, midwives, and doctors can play an important role in promoting the knowledge and awareness of pregnant mothers, and encouraging and referring them to receive oral health care during pregnancy. ⁹

This study had several limitations. This study relied on self-reported use of dental care rather than a review of dental records; however, woman's self-reports of use of care during the preceding year are widely used in health services research. The survey not considered the barriers “lack of dental insurance” and “cost,” therefore, we were unable to determine what proportion of our sample was uninsured for dental services.

The results from this study provide evidence of a high level not receipt dental care during pregnancy in Iran. Therefore, efforts are needed to remove barriers to receipt of dental care during pregnancy. While trying to eliminate the structural barriers of the health system, including increasing the coverage and increasing the access to care women in rural residence, unplanned pregnancy, and in parity women, it is necessary to develop appropriate policies for comprehensive education for society, especially pregnant women, about the importance of oral health during pregnancy.

Acknowledgments

The authors would like to thank the Research Center for Health Sciences affiliated to Shiraz University of Medical Sciences and the Research Vice-chancellors of Hormozgan University of Medical Sciences, Shiraz University of Medical Sciences, and other universities cooperating in this project.

Financial support and sponsorship

Nil.

Conflicts of interest

The authors of this manuscript declare that they have no conflicts of interest, real or perceived, financial or non-financial in this article.