Antenatal care has long been endorsed as the means to improve pregnancy outcomes by promoting preventive health care and healthy behaviours. Given the wide array of problems associated with pregnancy, good oral health care is essential for antenatal mothers. However, the important contribution of oral health to antenatal care is still not widely appreciated. An integrated and comprehensive approach to antenatal care requires oral health to be a compulsory component in the complex of interventions that a pregnant woman receives from any organized health care services. It means that dental examination should form the basic activities of antenatal care along with blood pressure monitoring, weight gain assessment, and obstetric examination. It is quite distressing, however, that the World Health Organization has not included oral health care as one of the basic component in the new antenatal care model .
Studies had shown that most women do not attend dental services during pregnancy. In the United States, analysis of the Pregnancy Risk Assessment Monitoring System (PRAMS) data in 1998 from the states of Arkansas, Illinois, Louisiana, and New Mexico revealed that only between 23% to 35% of pregnant women reported dental care use during pregnancy . In another analysis of PRAMS data from Washington, dental visits during pregnancy were reported by 42% of respondents . Other studies in the United States also showed that less than half of women visited dentist during their pregnancy [21, 23].
In the United Kingdom, oral health care forms an integral part of antenatal care. Dental services are exempted from the National Health Services fee to all pregnant mothers up until 12 months post-partum. However, a study done among a sample of immigrant women in North London showed an attendance rate of only 32% . In Northern Greece, only 27.3% of women reported visit to the dentist during their pregnancy , and in Kuwait, just a bit more than half of antenatal mothers (52%) utilized dental services . In this study, the utilisation of oral health care services among the antenatal mothers was 29%.
It was noted that this prevalence was higher than that ever reported by the Ministry of Health Malaysia . The most possible explanation for this is that the uptake of services reported by the Ministry of Health was obtained by dividing the number of new antenatal attendances to government dental facilities by the total number of new antenatal attendances to the Maternal and Child Health clinics in the particular year. Data obtained are used by the Ministry to monitor and evaluate the oral health care program as well as to facilitate in planning for resources. Thus, only visits to the government facilities were counted, whereas in this study, the definition of dental visit comprises of visit to both the government and the private clinics. Given the fact that more mothers preferred private dentists in this study, it is therefore appropriate that a higher prevalence was obtained. However, considering that the attendance rate for antenatal care in Malaysia from year 2000 to 2007 was only 79% , the problems of poor utilisation of dental services may be bigger than that revealed in this study.
Poor socio-economic conditions as indicated by low education level, unemployment and small household income, are important factors found to be associated with lesser likelihood of not going for a dental visit during pregnancy [20, 21, 24]. However, the influence of these factors on mothers' dental visit was not apparent in this study. Similar findings were reported by Dinas et al. . Instead, the situation seems to be in reverse in this study where the prevalence of dental visit was lower in mothers with tertiary education, who were working, and had higher household income. The most logical explanation for this is that higher education may lead to job with better salaries that keep the mothers very busy. Although the differences were not significant, further investigation in this matter may be warranted.
The knowledge that dental treatment is offered free of charge at government dental clinics was not associated with the mothers' dental visit. This finding indicates that the availability of free dental services is not fully appreciated by the mothers such that the services were not utilised to the maximum benefit. This is in contrast to previous report by Dinas et al. that mothers who visited dentist during their pregnancy were significantly more likely to know that dental treatment is free of charge . The results of this study also showed that perceived oral health status and self-reported oral health problems did not make a significant difference as to whether or not the mothers visit a dentist. A study by in Kuwait also found that perceived oral health problems was not a factor associated with dental visit among antenatal mothers . Similar results were obtained by other authors [20, 23]. These results reflect the mothers' poor attitude towards oral health care that needs to be addressed.
The results of this study revealed that mothers who reported dental visit were more likely to be those who had received oral health education before the current pregnancy and knew of the association between poor maternal oral health and adverse pregnancy outcomes. This is consistent with a study by Al-Habashneh et al. that mothers who have heard about the possible connection between oral health and pregnancy were significantly more likely to report dental visit during pregnancy . These findings further established the important roles of oral health education to impart knowledge and increase awareness that would in turn improve the mothers' dental care-seeking behaviour. Hence, the provision of oral health education to all antenatal mothers should be made mandatory in effort to improve uptake of services. Besides, oral health education could be used as a behavioural technique to alleviate dental fear among the mothers by making them more at ease and familiar with the dentist and the forthcoming treatment procedures. All misperceptions and erroneous conception about the safety of dental treatment that may contribute to the low rate of service utilisation can be corrected.
Patient satisfaction with the quality of services is an essential component of health care. It affects patients' use of services, compliance to care, and is also associated with health status and outcomes . Waiting time is an important quality indicator in measuring the outcome of any medical service. Extended waiting time at the dental clinic and substantial delay in receiving the needed care had resulted in patient dissatisfaction with the care provided [29, 30]. For most mothers in this study, time was an important essence as reflected in their responses that they were busy either at work or running the household chores. Consequently, 'late appointment' and 'long waiting time' were important barriers that prevent access to oral health care services among them.
Poor dentist to population ratio may contribute to some of the disappointments with the services rendered. The total number of dentists in Malaysia in year 2008 stood at 3,640 that gave an overall dentist to population ratio at 1 to 7,618 . Although there were more dentists in the public sector (52.8%) than in the private practice, a considerable number of them were actually at administrative posts that may reduce the proportion further. Results of this study showed that most mothers visited private dentists for their oral health care during pregnancy. This is possibly because most participants were working mothers and that they may have additional disposable income. Besides, as time is an important limitation for most of them, visiting a private practitioner may be a more convenient option since private clinics are mostly accessible after hours and during weekends. Waiting time at private clinics is also relatively short and treatment can be started immediately . It is therefore timely for the private dentists to take more active role in oral health promotion and services to antenatal mothers. Collaborative efforts between the Ministry of Health and the Malaysian Private Dental Practitioners' Association are recommended so as to ensure delivery of a more accessible oral health care program for antenatal mothers in this country.
Most oral diseases are silent in nature such that people tend to delay treatment. The majority of mothers in this study who did not attend dental clinic claimed that they had no dental problem. In fact, most mothers perceived their oral health status to be good or very good. On the other hand, many of them also reported having problems with their teeth and gum. This implies that the mothers did not perceive their oral health care as an urgent need and would rather delay visit until after delivery. These results concurred with other studies [17, 22, 23]. Another mistaken belief among mothers in this study was that dental treatment during pregnancy is harmful to the foetus. This misconception was reported as the most important factor limiting access to dental care among antenatal mothers in Northern Greece . Dental fear, particularly to dental pain was also reported by some mothers, and it is well documented that dental fear and anxiety have significant impact on dental care use behaviours [33–35].
The medical doctors and nurses are the front liners in antenatal care. Their responsibilities in oral health care provision are mainly to recommend dental referral to all antenatal mothers and to emphasis the importance of good oral health care. Hence, it is imperative that they too are aware of the current evidence linking maternal oral health and pregnancy outcomes. Conversely, studies have shown that medical practitioners do not regard oral health care as an essential part of antenatal care, and that most of them do not routinely advise their antenatal patients to seek dental care [36, 37]. This is apparent from the results of this study that only five mothers (13.9%) were referred by their doctors or nurses for dental visit. As such, continuing education to the medical providers on the current issue is deemed necessary. In addition, there should be mechanisms that can effectively facilitate communication and encourage cross-referral between dental and medical health care providers. Immediate action to revise the existing referral system in this country that has been in place for almost four decades is very much needed.