Barriers and facilitators to dental care during pregnancy: a systematic review and meta-synthesis of qualitative studies

Rocha, Juliana Schaia; Arima, Letícia; Chibinski, Ana Cláudia; Werneck, Renata Iani; Moysés, Samuel Jorge; Baldani, Márcia Helena

doi:10.1590/0102-311X00130817

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REVISÃO • Cad. Saúde Pública 34 (8) • 2018 • https://doi.org/10.1590/0102-311X00130817 copy

Barriers and facilitators to dental care during pregnancy: a systematic review and meta-synthesis of qualitative studies

Barreiras e facilitadores para os cuidados de saúde bucal durante a gravidez: uma revisão sistemática e meta-síntese de estudos qualitativos

Barreras y facilitadores para el cuidado dental durante el embarazo: una revisión sistemática y metasíntesis de estudios cualitativos

Authorship SCIMAGO INSTITUTIONS RANKINGS

Some barriers to dental treatment during pregnancy are poorly understood, especially those related to psychosocial factors, which are better explored in qualitative studies. The aim of this systematic review was to explore the barriers and facilitators to dental care during pregnancy through a thematic synthesis of qualitative studies. Qualitative or mixed-methods studies published in English, Portuguese, Spanish and French, from 2000 to 2016, were included. The search strategies were conducted in PubMed, Scopus, Web of Science, LILACS, BBO and CINAHL. To evaluate the quality of the studies, we used the Critical Appraisal Skills Programme tool. Thematic synthesis was performed in order to interpret and summarize the results. From 2,581 screened studies, ten were included in the synthesis. We found 14 analytical themes related to barriers and facilitators to dental care during pregnancy that interacted in complex ways: physiological conditions, low importance of oral health, negative stigma regarding dentistry, fear of/anxiety toward dental treatment, mobility and safety, financial barriers, employment, time constraints, social support, lack of information, health professionals’ barriers, family and friends’ advice, beliefs and myths about the safety of dental treatment. Myths and beliefs about oral health and dental treatment during pregnancy appear to be the most frequent barriers, both to pregnant women and to dentists or other health professionals. The findings of this review may support new studies, especially to test intervention protocols and to guide effective public policies for the promotion of oral health during pregnancy.

Keywords:
Pregnancy; Oral Health Services; Oral Health; Qualitative Research

CINAHL with text in full (via EBSCO)
S9	(((S1 OR S2 OR S3 OR S4 OR S5) AND (S6 OR S7 OR S8))
S8	AB pregnancy OR AB “pregnant women” OR AB “pregnant woman” OR AB pregnant
S7	TI pregnancy OR TI “pregnant women” OR TI “pregnant woman” OR TI pregnant
S6	MH pregnancy
S5	AB “dental care” OR AB “oral health” OR AB “dental health services” OR AB “oral services” OR AB “oral health care” OR AB “dental visits” OR AB “perceived oral health” OR AB “oral health services”
S4	TI “dental care” OR TI “oral health” OR TI “dental health services” OR TI “oral services” OR TI “oral health care” OR TI “dental visits” OR TI “perceived oral health” OR TI “oral health services”
S3	MH dental health services
S2	MH dental care
S1	MH oral health
LILACS and BBO (via Bireme)
#1 (mh:(“pregnancy”)) OR (ab:(“gravidez”)) OR (ti:(“gravidez”))OR (ab:(“embarazo”)) OR (ti:(“embarazo”))	#2 (ab:("dental care")) OR (ti:("dental care")) OR (mh:("dental care")) OR (mh:("oral health")) OR (ab:("oral health")) OR (ti:("oral health")) OR (ab:("dental health services")) OR (ti:("dental health services")) OR (mh:("dental health services")) OR (ab:("dental visits")) OR (ti:("dental visits")) OR (ab:("saúde bucal")) OR (ti:("saúde bucal")) OR (ab:("atención odontológica")) OR (ti:("atención odontológica")) OR (ab:("assistência odontológica")) OR (ti:("assistência odontológica")) OR (ab:("serviços de saúde bucal")) OR (ti:("serviços de saúde bucal"))
#1 and #2
PubMed
#1pregnancy[MeSH Terms] OR pregnant women[MeSH Terms] OR ‘pregnant women”[Title/Abstract] OR “pregnant woman”[Title/Abstract] OR pregnancy[Title/Abstract]	#2oral health[MeSH Terms] OR “oral health”[Title/Abstract] OR dental care[MeSH Terms] OR dental health services[MeSH Terms] OR “dental care”[Title/Abstract] OR “dental health services”[Title/Abstract]) OR “oral services”[Title/Abstract] OR “oral health care”[Title/Abstract]) OR “dental visits”[Title/Abstract] OR “perceived oral health”[Title/Abstract] OR “oral health services”[Title/Abstract]
#1 and #2
Web of Science
#7	#6 AND #5
#6	#4 OR #3
#5	#2 OR #1
#4	TI=(“dental care” OR “oral health” OR “dental health services” OR “oral services” OR “oral health care” OR “dental visits” OR “perceived oral health” OR “oral health services”)
#3	TS=(“dental care” OR “oral health” OR “dental health services” OR “oral services” OR “oral health care” OR “dental visits” OR “perceived oral health” OR “oral health services”)
#2	TI=(pregnancy OR “pregnant women” OR “pregnant woman” OR pregnant) OR TS=(pregnancy OR “pregnant women” OR “pregnant woman” OR pregnant)
#1	TS=(pregnancy OR “pregnant women” OR “pregnant woman” OR pregnant) OR TS=(pregnancy OR “pregnant women” OR “pregnant woman” OR pregnant)

Author (year)	Country/Setting	Participants	Objectives	Data collection/Analysis	Quality score (CASP)
Albuquerque et al. ³³33. Albuquerque OMR, Abegg C, Rodrigues CS. Percepção de gestantes do Programa Saúde da Família em relação a barreiras no atendimento odontológico em Pernambuco, Brasil. Cad Saúde Pública 2004; 20:789-96. (2004)	Brazil/Public health system	Pregnant women in the third trimester who did not seek dental care during pregnancy (3 focus groups with 4 to 9 pregnant women)	To identify and analyze qualitatively individual barriers to the dental care of pregnant women enrolled in the Family Health Program	Focus groups/Thematic analysis	8.5
Finkler et al. ³⁴34. Finkler M, Oleiniski DMB, Ramos FRS. Saúde bucal materno-infantil: um estudo de representações sociais com gestantes. Texto Contexto Enferm 2004; 13:360-8. (2004)	Brazil/Public and private health system	Women attending their antenatal consultation (n = 12)	To understand the social representations of pregnant women about babies’ oral health, influence of her oral health on the child’s health and the role of promoting oral health for their future child	Face-to-face interviews/Thematic analysis	8
Codato et al. ³⁵35. Codato LA, Nakama L, Melchior R. Percepções de gestantes sobre atenção odontológica durante a gravidez. Ciênc Saúde Coletiva 2008; 13:1075-80. (2008)	Brazil/Public and private (insurance) health system	Women around 3 gestational trimesters, of different educational levels, and amount of pregnancies (10 interviewed for each group) (n = 20)	To discuss pregnant women’s perceptions about dental care during pregnancy	Face-to-face interviews/Thematic analysis	9
Le et al. ³⁸38. Le M, Riedy C, Weinstein P, Milgrom P. Barriers to utilization of dental services during pregnancy: a qualitative analysis. J Dent Child 2009; 76:46-52. (2009)	USA/Medicaid community program	Pregnant women who had delivered their baby divided into 4 strata (with use or not of dental services/primiparous vs. multiparous) (n = 51)	To understand why women in Klamath Country in the Oregon pilot program did not use the dental services offered, and to provide a basis for planning an expansion of the program.	Telephone interviews/Ground theory approach	8.5
Leal et al. ³⁷37. Leal NP, Jannotti CB. Saúde bucal da gestante atendida pelo SUS: práticas e representações de profissionais e pacientes. Femina 2009; 37:413-21. (2009)	Brazil/Public health system	Pregnant women enrolled who performed at least 2 prenatal consultations (n = 23) [Interviews with doctors (14) and dentists (12) not considered]	To understand how practices and representations of prenatal care professionals, dentists, and pregnant women about dental care function during pregnancy and how they could interfere in the demand and adherence to dental care	Face-to-face interviews/Thematic analysis	8.5
Detman et al. ³¹31. Detman LA, Cottrell BH, Denis-Luque MF. Exploring dental care misconceptions and barriers in pregnancy. Birth 2010; 37:318-24. (2010) *	USA/Resident of Florida counties	Pregnant African American (1 month after the birth of their baby) (n = 253)	To explore Florida women’s experience of barriers in obtaining dental care before and during their pregnancies	Face-to-face interviews/Thematic analysis	9
Codato et al. ³⁶36. Codato LAB, Nakama L, Cordoni Júnior L, Higasi MS. Atenção odontológica à gestante: papel dos profissionais de saúde. Ciênc Saúde Coletiva 2011; 16:2297-301. (2011)	Brazil/Public and private (insurance) system	Pregnant women around 3 trimesters of gestation, who had to prenatal care in the Family Health Program and did not seek dental care during pregnancy	Are there barriers in the dental care of pregnant women? What is the nature of these barriers?	Face-to-face interviews/Content analysis	7.5
George et al. ⁴⁰40. George A, Johnson M, Duff M, Ajwani S, Bhole S, Blinkhorn A, et al. Midwives and oral health care during pregnancy: perceptions of pregnant women in south‐western Sydney, Australia. J Clin Nurs 2012; 21:1087-96. (2012)	Australia/Women attending their antenatal consultation at a large metropolitan hospital in south-western Sydney	Pregnant women residing in south-western Sydney (n = 10)	To explore the perceptions of pregnant women towards oral health and care during pregnancy and midwives providing oral education, assessment, and referrals as part of antenatal care	Telephone interviews/Thematic analysis	8
Nogueira et al. ³²32. Nogueira LT, Valsecki Júnior A, Martins CR, Rosell FL, Silva SRC. Retardo na procura do tratamento odontológico e percepção da saúde bucal em mulheres grávidas. Odontologia Clínico-Científica 2012; 11:127-31. (2012)*	Brazil/Central health office of the municipality and the Araraquara dental school	Women with children up to 5 years (sample 200) and who have needed some type of dental intervention during pregnancy	To explore the perception of their oral health and possible reasons that led these women to seek dental care during pregnancy	Face-to-face interviews/Unclear	5
Concha-Sánchez ³⁹39. Concha-Sánchez SC. El proceso salud-enfermedad-atención bucal de la gestante: una visión de las mujeres con base en la determinación social de la salud. Rev Fac Med (Bogotá) 2013; 61:275-91. (2013)	Colombia/ Hospitals and emergency care units	Pregnant women divided into: those who went to prenatal care and those who did not; those who attended a dental consultation and those did not; and those with periodontal disease and those without it (n = 18)	To explore the perceptions of individual, social and structural level that can influence the attention and assistance to dental consultations of pregnant women	Face-to-face interviews/Thematic analysis	8.5

	Albuquerque et al. ³³33. Albuquerque OMR, Abegg C, Rodrigues CS. Percepção de gestantes do Programa Saúde da Família em relação a barreiras no atendimento odontológico em Pernambuco, Brasil. Cad Saúde Pública 2004; 20:789-96. (2004)	Finkler et al. ³⁴34. Finkler M, Oleiniski DMB, Ramos FRS. Saúde bucal materno-infantil: um estudo de representações sociais com gestantes. Texto Contexto Enferm 2004; 13:360-8. (2004)	Codato et al. ³⁵35. Codato LA, Nakama L, Melchior R. Percepções de gestantes sobre atenção odontológica durante a gravidez. Ciênc Saúde Coletiva 2008; 13:1075-80. (2008)	Le et al. ³⁸38. Le M, Riedy C, Weinstein P, Milgrom P. Barriers to utilization of dental services during pregnancy: a qualitative analysis. J Dent Child 2009; 76:46-52. (2009)	Leal et al. ³⁷37. Leal NP, Jannotti CB. Saúde bucal da gestante atendida pelo SUS: práticas e representações de profissionais e pacientes. Femina 2009; 37:413-21. (2009)	Detman et al. ³¹31. Detman LA, Cottrell BH, Denis-Luque MF. Exploring dental care misconceptions and barriers in pregnancy. Birth 2010; 37:318-24. (2010)	Codato et al. ³⁶36. Codato LAB, Nakama L, Cordoni Júnior L, Higasi MS. Atenção odontológica à gestante: papel dos profissionais de saúde. Ciênc Saúde Coletiva 2011; 16:2297-301. (2011)	George et al. ⁴⁰40. George A, Johnson M, Duff M, Ajwani S, Bhole S, Blinkhorn A, et al. Midwives and oral health care during pregnancy: perceptions of pregnant women in south‐western Sydney, Australia. J Clin Nurs 2012; 21:1087-96. (2012)	Nogueira et al. ³²32. Nogueira LT, Valsecki Júnior A, Martins CR, Rosell FL, Silva SRC. Retardo na procura do tratamento odontológico e percepção da saúde bucal em mulheres grávidas. Odontologia Clínico-Científica 2012; 11:127-31. (2012)	Concha-Sánchez e ³⁹39. Concha-Sánchez SC. El proceso salud-enfermedad-atención bucal de la gestante: una visión de las mujeres con base en la determinación social de la salud. Rev Fac Med (Bogotá) 2013; 61:275-91. (2013)
Was there a clear statement of the aims of the research?	1	1	1	1	1	1	1	1	1	1
Is qualitative methodology appropriate?	1	1	1	1	1	1	1	1	1	1
Was the research design appropriate to address the aims of the research?	1	1	1	0.5	1	1	0.5	0	1	1
Was the recruitment strategy appropriate to the aims of the research?	1	0.5	0.5	1	1	1	0.5	1	0	1
Was the data collected in a way that addressed the research issue?	0.5	1	0.5	1	0.5	1	0.5	1	1	0.5
Has the relationship between researcher and participants been adequately considered?	0	0	1	0	0	0	0	0	0	0
Have ethical issues been taken into consideration?	1	1	1	1	1	1	1	1	1	1
Was the data analysis sufficiently rigorous?	1	0.5	1	1	1	1	1	1	0	1
Is there a clear statement of findings?	1	1	1	1	1	1	1	1	0	1
How valuable is the research?	1	1	1	1	1	1	1	1	0	1
Total	8.5	8	9	8.5	8.5	9	7.5	8	5	8.5

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[1] Correspondence J. S. Rocha Universidade Estadual de Ponta Grossa. Av. General Carlos Cavalcanti 4748, Ponta Grossa, PR 84.030-900, Brasil. julianaschaia@hotmail.com