By Zia Saylor

“I used to have perfect teeth. Like perfect teeth. I actually was a dental assistant back in my 20s. And I didn't have [my] first cavity until I had my first child.”  Cheryl*, a mother whom we interviewed for the recent publication “You Do Without”: Barriers to Oral Health Care and Consequences for Hoosiers, wistfully recalled that for many years, she “had beautiful teeth, just naturally.” What changed for her, however, was navigating pregnancy; what is often a time of joyous family growth also presents significant risks to oral health for women. The risks of dental caries (more colloquially, cavities), gingivitis, periodontitis, and mouth tumors all increase during pregnancy, with gingivitis among the most common oral health challenges (an estimated 60-75% prevalence rate among pregnant women). These statistics emphasize that Cheryl, who began her oral health journey without challenges and soon needed tooth removals, isn’t alone. Hormonal shifts, dietary changes, and morning sickness can all affect oral health during pregnancy.

Despite oral health challenges being common amongst pregnant women, there has been little policy action in Indiana to address this critical need. One policy barrier that Hoosiers in Indiana must contend with is limited Medicaid coverage of preventative treatments, which might prevent pregnancy-related oral health harms. For the reactive treatments that Medicaid covers, there is often a cap that prevents women from fully addressing the oral health complications they face during pregnancy.

Affordability—across populations with Medicaid, private insurance, or no insurance—also remains a critical component of oral health care accessibility for pregnant women. A research review of 31 papers published about pregnant women and oral health barriers found that cost was a common barrier. Cheryl had private dental insurance but still struggled to pay the costs associated with the treatment she would have needed to address her oral health needs. Cheryl reflected that, “Like [our] job offers insurance and we can't afford to use it cause [we] got to pay, like, three grand in deductibles before it kicks in.” Cheryl added that “both [me and my husband] are partially done [with our dental work] because we just can't afford to get the rest done right now, even though we have dental—we have dental insurance, but it's like we only have $300, maybe $200 left over after every paycheck to, you know, for food and gas and stuff.” The overall high costs of treatment—especially during and after a time such as pregnancy, when many medical appointments and supplies are needed—can then fall down the list of priorities, even as maintaining oral health contributes to the well-being of mother and child.

Cost poses a significant barrier to accessing oral health care, particularly during pregnancy, but another less visible resource that may limit access to care is paid time off. Because women in Indiana lack paid family leave, they may save their time off for the birth of their child and forgo necessary appointments during pregnancy. This risk is particularly high because workers in Indiana are not even guaranteed paid sick days, with only 80% of privately employed workers having access to this necessity, and only 58% of those in the lowest wage quartile. The result is that low-income pregnant women are more likely than their higher-income counterparts not to have access to even paid sick days to cover any necessary oral health needs that may arise during pregnancy. Not having paid sick days or paid leave may not seem like policies that would greatly affect oral health access, but it means that women must choose between financial well-being and oral healthcare access at a vulnerable time in their lives and family-building. Although the effects of paid leave or paid sick days on oral health have not been directly studied, early research indicates that access to paid leave increases attendance at postpartum check-ups, highlighting how lack of time and pressure on mothers can lead to unmet health needs. Taking the day off is not always feasible, and this can be compounded by long travel times, particularly amongst those living rurally in Indiana, to access specialist oral health care or in-network providers.

The cumulative impact of these policy layers is one of deep harm to pregnant women. One study estimated that less than half (44%) of pregnant women received dental cleanings, even as research agrees that pregnant women have an elevated risk for oral health complications. Simultaneously, in addition to the holistic well-being of mothers being harmed through difficulties in accessing oral health care, there are significant risks to the well-being of infants that can also increase. Maternal oral health complications during pregnancy have been linked to outcomes including low birthweights, pre-term births, and dangerous conditions for mother and child such as pre-eclampsia. Oral health care thus becomes a critical component of health, with impacts and implications beyond the individual: community and family health become linked to these outcomes, highlighting the imperative to intervene with policy solutions amid this crisis of oral health access.

Ensuring expectant mothers can access oral health care is a critical policy priority, and one that intersects with many policy systems, as explored in this blog. One urgent takeaway, however, is that the current system is not equipped to support oral health well-being among pregnant Hoosiers. Cheryl highlighted that oral health intersects with many policy systems and that, as much as brushing and flossing are good, they don't guarantee oral well-being, which is rooted in deeper issues of oral healthcare accessibility. She pointed out about herself and her husband: “We always went to the dentist. We brush our teeth daily.” Even as Cheryl and her husband took routine care of their teeth, they still had additional oral health needs that went unmet in Indiana.

Cheryl’s experience illustrates a common phenomenon: even for people who do the right thing in daily oral health habits, unexpected impacts can arise from life changes such as pregnancy. In turn, a lack of supportive policy can create significant barriers to accessing care and increase risks for families. As Indiana grows and continues to welcome rising generations of Hoosiers, ensuring expectant mothers and infants can access the oral health care necessary for long-term well-being is a critical way to create healthier families and communities. Cheryl, herself offering legislative suggestions for policymakers to consider, perhaps put it most succinctly: “[We need] affordable dental stuff, like just making it affordable for everyone. I mean, teeth are important, you know what I mean?”

This project was made possible through a partnership with CareQuest Institute for Oral Health.

*We use pseudonyms to protect the identity of individuals