Oral health and other characteristics of pregnant Aboriginal women compared with general population estimates
Address for correspondence:
Dr Lisa M Jamieson
Australian Research Centre for Population Oral Health
School of Dentistry
The University of Adelaide
Adelaide SA 5005
Aboriginal and Torres Strait Islander Australians have around five times the prevalence of dental disease experience than non-Aboriginal Australians,[1, 2] and profound oral health inequalities have been noted. There are high levels of periodontal disease (up to 90% in some Aboriginal adult groups compared with one-quarter in non-Aboriginal adults), particularly given the links between periodontal disease and a range of chronic conditions such as diabetes, cardiovascular disease and kidney disease. Whilst improvements in many areas of Aboriginal health have been noted, the oral health of this vulnerable population is decreasing. There is evidence that oral health is considered an important component of general health and well-being among Aboriginal groups, who see that ‘Closing the Gap includes Closing the Oral Health Gap’.
An important group within the Aboriginal population in terms of oral health risk are pregnant women. Dental services during pregnancy can improve maternal oral health, reduce mother-child transmission of cariogenic bacteria and create opportunities for anticipatory guidance. Many women do not see the importance of oral care during pregnancy, while others experience barriers to care, such as not having dental coverage and access to care.
This report examines the oral health and other key characteristics of pregnant Aboriginal women and compares against population benchmarks. This is a nested study within an over-arching randomized control trial known as ‘Baby Teeth Talk’ (BTT).
To be eligible, participants needed to be pregnant residents of South Australia, expecting an Aboriginal Australian baby or babies or to have recently birthed an Aboriginal Australian baby or babies (infants less than six weeks of age).
Participants were recruited from a range of sources including referrals from Aboriginal groups, community services and hospitals. Promotion of the study occurred via: (1) advertisements in community and hospital newsletters; (2) posters in hospitals and community centres; and (3) word-of-mouth. Questionnaires were completed in participant homes, cafes, libraries, hospitals, community halls, Aboriginal resource centres and workplaces. Participants were provided with written and verbal information about the study prior to giving consent, and received a $50 gift voucher upon completion of the questionnaire.
Data were collected via questionnaires administered by both Aboriginal and non-Aboriginal project officers. The questionnaires were completed either independently by participants or through interview. The project officers had a scripted method of introducing and administering the questionnaire.
This study received approval from the University of Adelaide Human Research Ethics Committee, the Aboriginal Health Council of South Australia, the Government of South Australia and the Human Research Ethics Committees of participating Adelaide hospitals (e.g. Flinders Medical Centre, Lyell McEwin, Women's and Children's).
Variables of interest
Variables of interest in this study were encapsulated into six domains: (1) socio-demography (age, Aboriginal or Torres Strait Islander, education, income, ownership of a means-tested government health care card, number of people in household the previous night); (2) dental service utilization (seen dentist before, when last saw dentist, where last saw dentist, usual reason see dentist, scared of dentist; (3) dental cost (avoided dental care because of cost, difficulty paying $100 dental bill); (4) self-rated health (self-rated general health, self-rated oral health); (5) dental perceptions (dental fear, need filling, need extraction, have gum disease); and (6) oral health impairment (toothache, uncomfortable about appearance, unable to eat food). Two summary oral health impairment items were constructed. Oral health impairment_any was considered a response of ‘very often’, ‘often’ or ‘sometimes’ to the items ‘How often in the past year … did you have toothache?’, ‘… did you feel uncomfortable about the way your teeth looked?’ or ‘… could you not eat some foods or had to eat slowly because of problems with your teeth?’. Oral health impairment_all was considered a response of ‘very often’, ‘often’ or ‘sometimes’ to the items ‘How often in the past year … did you have toothache?’, ‘… did you feel uncomfortable about the way your teeth looked?’ and ‘… could you not eat some foods or had to eat slowly because of problems with your teeth?’.
For comparative purposes, results were compared with those of the National Survey of Adult Oral Health (NSAOH). NSAOH was a cross-sectional study of oral health among Australians aged 15 years or more living in all states and territories. NSAOH utilized a three-stage, stratified clustered sampling design. The first stage selected postcodes, the second stage selected households within sampled postcodes and the third stage selected one adult from each sampled household. Because of the differences in the probability of participation, data were weighted to ensure estimates were representative of the Australian population from which survey participants were selected. Weights were calculated to reflect probabilities of selection and to adjust for different participation rates across postcodes, and among age and gender categories. For the purposes of this analysis, NSAOH data were restricted to females and the age range reflected that of the Aboriginal sample.
Data were analysed using PASW software version 20.0. Findings were considered to be statistically significant when 95% confidence intervals (CI) were not overlapping. Statistical analyses for the NSAOH component took into account the clustered sampling design to yield unbiased standard error estimates and design effects using the ‘complex sampling’ tool; thus producing weighted population estimates.
A total of 446 women pregnant with Aboriginal or Torres Strait Islander children completed the questionnaire. The age range was 14 to 43 years, with the median age being 24.9 years (Table 1). Around four-fifths (79.5%) were 37 weeks pregnant or less and just under two-fifths (38.5%) were pregnant with their first child. Among those who were not pregnant with their first child, 42.8% already had four or more children. Among all participants, 68.2% cared for children who were not their own. Most (83.2) participants identified as being Aboriginal or Torres Strait Islander and the highest educational attainment for 71.6% of participants was high school or less. Nearly 90% (85.9%) of participants were unemployed, with 82.2% owning a means-tested government health care card. Over one-third of participants (34.7%) reported five or more people staying in their house the previous night and nearly half (49.1%) did not own a car.
Table 1. Socio-demographic characteristics
|14 to 24 years||52.2 (45.6–58.8)||22.4 (18.5–26.8)||2.3a|
|25 to 43 years||47.8 (40.9–54.7)||77.6 (73.2–81.5)||0.6|
|ABTSI||83.2 (79.4–87.0)||1.3 (0.7–2.5)||64.0a|
|Other||16.8 (8.2–25.4)||98.7 (97.5–99.3)||0.2|
|High school or less||71.6 (66.6–76.6)||34.7 (30.7–38.9)||2.1a|
|Trade, TAFE or University||28.4 (20.5–36.3)||65.3 (61.1–69.3)||0.4|
|Job||14.1 (5.4–22.8)||71.4 (67.7–74.9)||0.2a|
|Centrelink ||85.9 (82.4–89.4)||28.6 (25.1–32.3)||3.0|
|Health Care Card|
|Yes||82.2 (78.2–86.2)||22.5 (19.1–26.3)||3.7a|
|No||17.8 (9.2–26.4)||77.5 (73.7–80.9)||0.2|
|People in house previous night|
|Four or less||65.3 (59.7–70.9)||79.5 (75.6–82.9)||0.8a|
|Five or more||34.7 (27.0–42.4)||20.5 (17.1–24.4)||1.7|
Whilst the prevalence of BTT participants who had attended for dental care before was the same as population estimates (Table 2), a higher proportion last visited over one year previous (65% versus 45%). The prevalence of BTT participants who sought dental care in the public sector was six times that of their population-level counterparts and nearly two-thirds (65%) usually visited because of dental pain (compared to 44% of the general population). Interestingly, 60% of BTT participants reported not being afraid of the dentist, compared with 51% of their population-level counterparts.
Table 2. Dental service utilization characteristics
|Seen dentist before|
|Yes||97.1 (95.5–98.7)||100 (100.0–100.0)||1.0|
|No||2.9 (0–12.1)||0 (0.0–0.0)||0.0 |
|When last saw a dentist|
|Less than one year ago||35.3 (27.7–42.9)||55.4 (51.2–59.5)||0.6a|
|One or more years ago||64.7 (59.1–70.3)||44.6 (40.5–48.8)||1.5|
|Where last saw a dentist|
|ACCHO/public/SDS||73.9 (69.0–78.8)||12.6 (9.9–15.9)||5.9a|
|Private||26.1 (17.9–34.3)||87.4 (84.1–90.1)||0.3|
|Usual reason for seeing a dentist|
|Problem||64.5 (58.8–70.2)||40.9 (36.9–45.2)||1.6a|
|Check-up||35.5 (27.9–43.1)||59.1 (54.8–63.1)||0.6|
|Scared of dentist?|
|No||59.5 (53.5–65.5)||50.5 (46.4–54.6)||1.2|
|Little bit, fair bit, heaps||40.5 (33.3–47.7)||49.5 (45.4–53.6)||0.8|
Approximately two-thirds of BTT participants reported avoiding care because of cost (compared with 45% of their age- and gender-matched counterparts) and four-fifths reported they would find it a little bit, very hard or could not pay a $100 dental bill (compared with 55% of their population-level counterparts; Table 3).
Table 3. Cost-related characteristics
|Not gone to dentist in last year because of cost|
|Yes||35.5 (28.0–43.0)||44.7 (40.5–48.9)||0.8|
|No||64.5 (58.9–70.1)||55.3 (51.1–59.5)||1.2|
|How hard would it be to pay a $100 dental bill?|
|Not hard at all or not very hard||19.7 (11.3–28.1)||43.8 (39.8–47.9)||0.4a|
|A little bit or very hard, or could not pay||80.3 (76.1–84.5)||56.2 (52.1–60.2)||1.4|
Although there were no statistically significant differences with regard to self-reported general health among BTT participants and population estimates (Table 4), 54% of BTT participants rated their oral health as ‘fair or poor’ compared with 14% of the general population. Twice as many BTT participants reported a need for fillings (66% versus 31%). The prevalence of BTT participants reporting a need for extractions was six times that of population-level estimates.
Table 4. Self-rated health, self-rated oral health and dental perception characteristics
|How do you think your general health is:|
|Excellent, very good or good||90.3 (87.4–93.2)||94.1 (91.9–95.7)||1.0|
|Fair or poor||9.7 (0.8–18.6)||5.9 (4.3–8.1)||1.6|
|How do you think your oral health is:|
|Excellent, very good or good||45.7 (38.8–52.6)||86.5 (83.1–89.3)||0.5a|
|Fair or poor||54.3 (48.0–60.6)||13.5 (10.7–16.9)||4.0|
|Yes||65.9 (60.4–71.4)||31.1 (27.1–35.4)||2.1a|
|No||34.1 (26.5–41.7)||68.9 (64.6–72.9)||0.5|
|Need teeth pulled out?|
|Yes||50.3 (43.7–56.9)||8.4 (6.1–11.5)||6.0a|
|No||49.7 (43.0–56.4)||91.6 (88.5–93.9)||0.5|
Table 5. Oral health impairment characteristics
|How often during the last year did you… have toothache very often, fairly often or sometimes?|
|Yes||54.9 (48.6–61.2)||20.9 (17.4–24.9)||2.6a|
|No||45.1 (38.2–52.0)||79.1 (75.1–82.6)||0.6|
|… feel uncomfortable about the way your teeth looked very often, fairly often or sometimes?|
|Yes||61.6 (55.8–67.4)||26.6 (23.2–30.3)||2.3a|
|No||38.4 (31.1–45.7)||73.4 (69.7–76.8)||0.5|
|… have to avoid eating some foods because of problems with your teeth very often, fairly often or sometimes?|
|Yes||54.1 (47.8–60.4)||18.7 (15.3–22.6)||2.9a|
|No||45.9 (39.0–52.8)||81.3 (77.4–84.7)||0.6|
|In the last year, did you have toothache OR felt uncomfortable about appearance OR avoided foods very often, fairly often or sometimes?|
|Yes||78.7 (74.4–83.0)||43.4 (39.2–47.6)||1.8a|
|No||21.3 (13.0–29.6)||56.6 (52.4–60.8)||0.4|
|In the last year, did you have toothache AND felt uncomfortable about appearance AND avoided foods very often, fairly often or sometimes?|
|Yes||33.9 (26.3–41.5)||5.2 (3.4–7.8)||6.5a|
|No||66.1 (60.7–71.5)||94.8 (92.2–96.6)||0.7|
A higher proportion of BTT participants reported having toothache, discomfort about appearance and food avoidance compared with population-level estimates (with BTT/NSAOH ratios of 2.6, 2.3 and 2.9 respectively). Although this disparity attenuated somewhat when the oral health impairment_any measure was considered (BTT/NSAOH ratio of 1.8), it increased markedly when considering the more severe measure of oral health impairment (oral health impairment_all; BTT/NSAOH ratio of 6.5).
Profound social and oral health inequalities were observed when comparing a convenience sample of pregnant Aboriginal women in South Australia with their national-level counterparts. This was particularly apparent with consideration of ownership of a means tested health care card, last seeking dental care in the public setting, ‘fair’ or ‘poor’ self-rated oral health, perceived need for tooth extractions and oral health impairment.
That the self-rated general health of the Aboriginal population did not differ substantially from population estimates, yet was markedly worse when oral health was considered, indicates that oral health related problems contribute substantially to general health related quality of life over and above issues pertaining to general health. This has been reported among other convenience samples of Aboriginal and Torres Strait Islander Australians, as well as among other vulnerable populations such as homeless groups. The phenomenon does not appear to be as apparent among general population samples.
Perceived need for dental extractions indicates perhaps a fatalistic view of our Aboriginal sample that teeth causing pain or discomfort need to be removed as opposed to restored, which is certainly supported by qualitative reports. In the general population, the frames of reference for ‘teeth requiring extraction’ may be at a somewhat higher threshold; put another way, a greater proportion of the general population may understand the complexity of some dental care procedures that enable teeth to be restored as opposed to extracted, and may be more willing to undergo such care in order to keep teeth.
The high prevalence, relative to population estimates, of Aboriginal participants who recently experienced toothache, discomfort about dental appearance and food avoidance due to dental problems is concerning; particularly among a group for whom good nutrition and mental well-being is critical.
Our findings indicate that social and oral health inequalities among a population of pregnant Aboriginal women are profound and that ‘Closing the Gap’ initiatives in regards to oral health have some way to go before reaching their target aim.
This report was produced by Lisa Jamieson, Indigenous Oral Health Unit, Australian Research Centre for Population Oral Health. The Baby Teeth Talk study was funded by the National Health and Medical Research Council.