Our paper investigates how far dental professionals have come in adopting perinatal care practices that follow recommendations of the NY State Department of Health’s expert panel and the CDC. Attitudes are important and barriers clearly remain. Dentists indicated that high levels of perceived time and economic costs, and dissatisfaction with compensation by insurers, were significant barriers to provision of care for pregnant patients. Results from our analysis confirm that dentists’ attitudes have significant negative impacts on current practice.
The result of our analysis should be interpreted in light of several alternative theoretical models. While the model proposed in this paper examined dentists’ perceived barriers and number of pregnant patients as exogenous variables, it is possible that alternative models exist among the exogenous and endogenous variables in the proposed conceptual framework. For example, dentists with incorrect knowledge may perceive more barriers, and thus avoid caring for pregnant patients. Alternatively, dentists who care for a large number of pregnant patients and have low levels of incorrect knowledge might still perceive substantial barriers to caring for this patient population. We tested both of these alternative models, and the results in the final model were more consistent with our hypotheses.
The delivery of perinatal health for the 62 million pregnant women in the US requires a multi-strategy, action-oriented initiative that includes all healthcare professionals, dental and obstetrics professionals and takes advantage of every encounter with women to provide preconception counseling and services to alleviate possible health risks. Previous efforts to disseminate new clinical guidelines through natural diffusion have been slowed by the fragmentation of the current healthcare system. Until critical barriers including insufficient compensation from private or public insurance, compromised access to healthcare, and limited awareness among women in childbearing ages are alleviated, impediments to improving the health of women and children will continue. Women’s health significantly influences the future of children’s health. Only when women’s health issues are given a higher priority by public policy leaders, health care providers, and public and private insurers will there be substantial improvement in the oral and general health of the next generation.
The US is failing to achieve goals set in Healthy People 2010
for oral health. Interventions to address the goals will not be successful if they are not based on a thorough understanding of the complexity of problems. This study draws on previous work in health care to encourage providers to change practices or adopt new ones (Grol & Grimshaw, 2003
; Grol & Wensing, 2004
). Research in both dentistry and medicine indicates that multi-level interventions, which explicitly address the complex factors that govern care, are more effective than simple ones. In the Access to Baby and Child Dentistry
(ABCD) program in Washington State, (Grembowski & Milgrom, 2000
), the intervention included key leaders in the local dental community who endorsed dentists’ participation, involvement of paraprofessional staff members, changing dental professionals’ attitudes about Medicaid procedures and about Medicaid clients, reduction of barriers to participate (e.g. reducing problems with billing Medicaid; reducing no shows by low-income clients; higher fees for appropriate procedures); and courses for dentists to increase their knowledge of child management and care procedures. In the ABCD model, workers in local health departments served as parent advocates and counselors and provided case management. This multi-layered approach and community-specific approach increased access to care and dental visits dramatically (Grembowski & Milgrom, 2000
). It also changed the focus of care for young children from an episodic and symptom-oriented approach to one of disease prevention. . As a result of initial success, the program has grown (Kobayashi, et al., 2005
The results of the present study suggest that something similar to the ABCD
program is needed to overcome the limitations in the current system so pregnant women and women in the perinatal and interconception periods receive better dental care. However, the knowledge needed to build such an intervention is incomplete. For instance, different types of interventions may be needed to fit the different office contexts (e.g. private versus not for profit offices) and patient populations (e.g. Medicaid/racial/ethnic mix with cultural differences). An example of how such information can be used to tailor an intervention successfully is a pilot program that increased dental care utilization of women in Klamath County, Oregon (Milgrom, et al., 2008
). In this program, a county community health coalition identified oral health as a priority and worked with managed care organizations in dentistry and medicine to prioritize care for pregnant women and their young children. A dental hygienist counselor/case manager was hired to work with pregnant women, and the dental offices, to assure the women had timely access to dental care. The women were identified through the Women, Infant and Child (WIC) program in the local health department. The local dental hygiene training program served as an entry point for care. Physicians also made referrals for dental care. As a result, the proportion of pregnant women in the county who saw a dentist during pregnancy increased from 8.8 (before the program period) to nearly 56 percent. A challenge for practice and policy is to encourage field experiments to identify promising practices and then support their “scale up” to improve population health.