# Interprofessional survey on knowledge and attitudes of midwives regarding oral health, in France

Abid Bossouf, Céline Sabourin, Florent Fuchs, Nicolas Giraudeau, Camille Inquimbert

► To cite this version:

Abid Bossouf, Céline Sabourin, Florent Fuchs, Nicolas Giraudeau, Camille Inquimbert. Interprofessional survey on knowledge and attitudes of midwives regarding oral health, in France. European Journal of Midwifery, 2023, 7, pp.1-8. 10.18332/ejm/172881. hal-04379205

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Submitted on 8 Jan 2024

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Distributed under a Creative Commons Attribution 4.0 International License
# Interprofessional survey on knowledge and attitudes of midwives regarding oral health, in France

Abid Bossouf, Céline Sabourin, Florent Fuchs, Nicolas Giraudeau, Camille

Inquimbert

► To cite this version:

Abid Bossouf, Céline Sabourin, Florent Fuchs, Nicolas Giraudeau, Camille Inquimbert. Interprofessional survey on knowledge and attitudes of midwives regarding oral health, in France. European Journal of Midwifery, 2023, 7, pp.1-8. 10.18332/ejm/172881. hal-04379205

HAL Id: hal-04379205

https://hal.umontpellier.fr/hal-04379205v1

Submitted on 8 Jan 2024

HAL is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
recherche français ou étrangers, des laboratoires
publics ou privés.

<figure><img src="image_1.png" /></figure>

Distributed under a Creative Commons Attribution 4.0 International License
<figure><img src="image_2.png" /></figure>

# Interprofessional survey on knowledge and attitudes of midwives regarding oral health, in France

Abid Bossouf¹,², Céline Sabourin¹,³, Florent Fuchs⁴,⁵,⁶, Nicolas Giraudeau¹,², Camille Inquimbert¹,⁶

## ABSTRACT

**INTRODUCTION** Oral health is essential for psychosocial well-being and general health. For expectant mothers, pregnancy increases the risk of oral diseases and has a subsequent impact on the oral health of a child once born. Midwives are in charge of pregnancy monitoring, childbirth and newborns' first days of life. They could have an important role in prevention. However, limited studies evaluating the knowledge, attitudes and practices on oral health among midwives have been conducted in Europe.

**METHODS** We performed a cross-sectional study using a self-administered questionnaire. Two local midwifery associations sent out the questionnaire by email and social media networks to all registered midwives and practicing in the department of Herault (n=613), between April and May 2022. Statistical analyses on quantitative data and descriptive analyses of qualitative free-text responses were performed.

**RESULTS** In total, 167 midwives were included. We found a lack of knowledge on many oral health topics and this was stated as the main reason that only 29% of midwives provided oral health information to their patients. Only 30% of the midwives had a training module on oral health during their initial training, and less than half of them considered the training adequate. To improve their lack of knowledge, participants expressed a preference for digital communication methods for themselves; however, they favored in-person interaction for public interventions.

**CONCLUSIONS** This study showed a lack of training and knowledge about oral health among midwives and a lack of oral health discussion with expectant mothers who are a high-risk population for oral diseases.

## AFFILIATION

1. Department of Public Health, Faculty of Dental Medicine, University of Montpellier, Montpellier, France

2. Center for Latin European Political Studies, UMR 5112, CNRS, University of Montpellier, Montpellier, France

3. Team of Criminal Law and Forensic Sciences of Montpellier, UR-UM212, University of Montpellier, Montpellier, France

4. Department of Obstetrics and Gynecology, Montpellier University Hospital Center, Montpellier, France

5. National Institute of Health and Medical Research, Centre for Epidemiology and Population Health, Reproduction and child development, Paris, France

6. Desbrest Institute of Epidemiology and Public Health, University of Montpellier, Montpellier, France

Eur J Midwifery 2023;7(December):37

https://doi.org/10.18332/ejm/172881

## INTRODUCTION

Oral health is an essential part of the psychosocial wellbeing and general health of a person¹. The World Health Organization defines oral health as: 'the state of the mouth, teeth and orofacial structures that enables individuals to perform essential functions, such as eating, breathing and speaking, and encompasses psychosocial dimensions, such as self-confidence, well-being and the ability to socialize and work without pain, discomfort and embarrassment'; and that it 'varies over the life course from early life to old age, is integral to general health and supports individuals in participating in society and achieving their potential'².

High prevalence of oral health diseases is a public health concern. Worldwide, 3.5 billion people are affected by oral diseases and over 514 million children suffer from caries of primary teeth². In France, in 2019, almost 30% of children aged 1–9 years had untreated caries of deciduous teeth³. However, most oral health problems are avoidable if treated at an early stage and prevention is key in the fight against oral disease.

Pregnant women are a particularly high-risk population for oral health diseases. Multiple studies have shown a relationship between oral health during pregnancy and subsequent complications⁴⁻⁶. Yousefi et al.⁴ showed that the physiological changes involved during pregnancy can increase the risk of cavities, and Dye et al.⁵,⁶ found that untreated periodontal disease has a negative effect on pregnancy and on newborn health (such as premature birth, fetal growth restriction, or pre-eclampsia). Therefore, the mother's oral health is related to the future child's oral health⁵,⁶.

Among healthcare professionals, midwives have a unique role to play since they are in

## CORRESPONDENCE TO

Camille Inquimbert. Department of Public Health, Faculty of Dental Medicine, University of Montpellier, 34000 Montpellier, France.

E-mail: camille.inquimbert@umontpellier.fr

ORCID ID: https://orcid.org/0000-0002-3660-2391

## KEYWORDS

knowledge, pregnancy, midwives, attitude, literacy, oral health

<figure><img src="image_3.png" /></figure>

Received: 12 April 2023

Revised: 19 September 2023

Accepted: 3 October 2023
<figure><img src="image_2.png" /></figure>

# Interprofessional survey on knowledge and attitudes of midwives regarding oral health, in France

Abid Bossouf¹,², Céline Sabourin¹,³, Florent Fuchs⁴,⁵,⁶, Nicolas Giraudeau¹,², Camille Inquimbert¹,⁶

## ABSTRACT

**INTRODUCTION** Oral health is essential for psychosocial well-being and general health. For expectant mothers, pregnancy increases the risk of oral diseases and has a subsequent impact on the oral health of a child once born. Midwives are in charge of pregnancy monitoring, childbirth and newborns' first days of life. They could have an important role in prevention. However, limited studies evaluating the knowledge, attitudes and practices on oral health among midwives have been conducted in Europe.

**METHODS** We performed a cross-sectional study using a self-administered questionnaire. Two local midwifery associations sent out the questionnaire by email and social media networks to all registered midwives and practicing in the department of Herault (n=613), between April and May 2022. Statistical analyses on quantitative data and descriptive analyses of qualitative free-text responses were performed.

**RESULTS** In total, 167 midwives were included. We found a lack of knowledge on many oral health topics and this was stated as the main reason that only 29% of midwives provided oral health information to their patients. Only 30% of the midwives had a training module on oral health during their initial training, and less than half of them considered the training adequate. To improve their lack of knowledge, participants expressed a preference for digital communication methods for themselves; however, they favored in-person interaction for public interventions.

**CONCLUSIONS** This study showed a lack of training and knowledge about oral health among midwives and a lack of oral health discussion with expectant mothers who are a high-risk population for oral diseases.

## AFFILIATION

1 Department of Public Health, Faculty of Dental Medicine, University of Montpellier, Montpellier, France

2 Center for Latin European Political Studies, UMR 5112, CNRS, University of Montpellier, Montpellier, France

3 Team of Criminal Law and Forensic Sciences of Montpellier, UR-UM212, University of Montpellier, Montpellier, France

4 Department of Obstetrics and Gynecology, Montpellier University Hospital Center, Montpellier, France

5 National Institute of Health and Medical Research, Centre for Epidemiology and Population Health, Reproduction and child development, Paris, France

6 Desbrest Institute of Epidemiology and Public Health, University of Montpellier, Montpellier, France

## CORRESPONDENCE TO

Camille Inquimbert. Department of Public Health, Faculty of Dental Medicine, University of Montpellier, 34000 Montpellier, France.

E-mail: camille.inquimbert@umontpellier.fr

ORCID ID: https://orcid.org/0000-0002-3660-2391

## KEYWORDS

knowledge, pregnancy, midwives, attitude, literacy, oral health

<figure><img src="image_3.png" /></figure>

Received: 12 April 2023

Revised: 19 September 2023

Accepted: 3 October 2023

## INTRODUCTION

Oral health is an essential part of the psychosocial wellbeing and general health of a person¹. The World Health Organization defines oral health as: 'the state of the mouth, teeth and orofacial structures that enables individuals to perform essential functions, such as eating, breathing and speaking, and encompasses psychosocial dimensions, such as self-confidence, well-being and the ability to socialize and work without pain, discomfort and embarrassment'; and that it 'varies over the life course from early life to old age, is integral to general health and supports individuals in participating in society and achieving their potential².

High prevalence of oral health diseases is a public health concern. Worldwide, 3.5 billion people are affected by oral diseases and over 514 million children suffer from caries of primary teeth². In France, in 2019, almost 30% of children aged 1–9 years had untreated caries of deciduous teeth³. However, most oral health problems are avoidable if treated at an early stage and prevention is key in the fight against oral disease.

Pregnant women are a particularly high-risk population for oral health diseases. Multiple studies have shown a relationship between oral health during pregnancy and subsequent complications⁴⁻⁶. Yousefi et al.⁴ showed that the physiological changes involved during pregnancy can increase the risk of cavities, and Dye et al.⁵,⁶ found that untreated periodontal disease has a negative effect on pregnancy and on newborn health (such as premature birth, fetal growth restriction, or pre-eclampsia). Therefore, the mother's oral health is related to the future child's oral health⁵,⁶.

Among healthcare professionals, midwives have a unique role to play since they are in
<figure><img src="image_4.png" /></figure>

charge of pregnancy monitoring, childbirth and newborns' first day of life⁷. It could therefore be said that midwives should be equipped to act and promote oral health. Even though studies evaluating oral health knowledge and attitudes among midwives have mostly been conducted in the USA⁸,⁹ and Australia¹⁰,¹¹, limited studies have been carried out in Europe¹²⁻¹⁴. The objective of this study was to assess the oral health knowledge and attitudes of midwives in the department of Herault in France.

# METHODS

## Study design

An observational, descriptive, cross-sectional, multi-center study was conducted using a self-administered questionnaire. This pilot study was part of a bigger project called Montpellier Santé Orale and similar studies have been conducted for nurses, speech therapists, physiotherapists, pharmacists, pediatricians, and medical general practitioners (GPs).

## Sample and setting

Two local midwifery associations sent out the questionnaire by email and social media networks to all registered midwives and practicing in the department of Herault (n=613), between April and May 2022. A purposive sampling technique was used and informed consent was obtained from all participants.

The protocol and study design were approved by ethics and regulatory agencies and were implemented in accordance with provisions of the Declaration of Helsinki. The appropriate Committee (Montpellier University Hospital Institutional Review Board, Montpellier, France) approved the protocol (IRB 2022_10_202201250).

Participants had to sign the informed consent. The informed consent form contained the name and affiliation of the investigator, a plain language description of the study, and the ethics committee approval.

## Data collection

The questionnaire (Supplementary file) was developed as part of a collaborative multidisciplinary project and was based on the one conducted in Australia¹⁰. It was distributed online using Google Forms.

The first part of our questionnaire was relevant to all healthcare professionals (including midwives, nurses, speech therapists, physiotherapists, pharmacists, pediatricians, and medical general practitioners), whereas the second part was specifically given to midwives.

The questionnaire integrated both quantitative and qualitative elements. It was divided into four sections. There were three question types: five open-ended questions, eight yes or no questions, and five multiple choice questions. The first section collected information about the survey respondent's background and training. The level of teaching was based on the declarative values and perceptions of the participants. The second section (14 questions) assessed their understanding of the relationship between oral health and general health. The third section (17 questions)

assessed the respondent's understanding of prevention, hygiene habits, and the role of food/drink in oral health. Lastly, the fourth section collected information about the respondent's knowledge of the relationship between pregnancy and oral health, approach during consultations and oral health prevention strategies preferences for themselves as well as with the general population.

## Data analysis

Incomplete questionnaires were excluded from the study. Microsoft Excel was used to perform the statistical analysis and the results are presented in percentages. Participants with missing data were excluded from any analyses involving that data. Data regarding the oral health knowledge and attitudes of midwives was summarized using descriptive statistics including frequencies, means and standard deviations. The Mann-Whitney U test was used to check whether there was a difference in correct responses, depending on the initial training. The significance threshold was set at 5%.

# RESULTS

## Participants

The total sample comprised 167 midwives. The response rate was 31.5% (n=193) but we excluded 26 questionnaires: midwives not practicing in the department of Herault, or incomplete questionnaires.

Most participants were female (98.8%), aged 24-62 years, with a mean of 37.3 ± 9.85 years. Most (53.9%) participants reported working in a hospital setting, 34.7% in private practice and 16.2% in private clinic, with some overlap between the groups since many participants had multiple professional practices. A range of levels of experience was reported, with participants stating that they had practiced midwifery between 1 to 41 years (mean=13.1 years). More than 75.0%, however, stated that they practiced for <20 years.

Most respondents (62.3%) completed their training in the department of Herault. Overall, only 30% of the participants said that they had taken an oral health module during their training, and only 13.2% expressed that they received adequate training.

We found that the midwives who had received their credentials more recently were more likely to have received training on oral health (Figure 1). Of the 13 participants (7.8%) who had received training on oral health since their qualification, all had qualified in or before 2007.

## Knowledge

For the questions on the relationship between oral health and general health, we received correct answers for 75.8% of the time (Table 1). The least correctly answered question was on whether oral bacteria can reach the amniotic fluid and lead to infections in expectant mothers (47.9% of participants answered this correctly), whereas the most correctly answered question was about tobacco use and that it increases the risk of upper respiratory tract cancer (98.2% of participants answered this correctly).
<figure><img src="image_4.png" /></figure>

charge of pregnancy monitoring, childbirth and newborns' first day of life⁷. It could therefore be said that midwives should be equipped to act and promote oral health. Even though studies evaluating oral health knowledge and attitudes among midwives have mostly been conducted in the USA⁸,⁹ and Australia¹⁰,¹¹, limited studies have been carried out in Europe¹²⁻¹⁴. The objective of this study was to assess the oral health knowledge and attitudes of midwives in the department of Herault in France.

# METHODS

## Study design

An observational, descriptive, cross-sectional, multi-center study was conducted using a self-administered questionnaire. This pilot study was part of a bigger project called Montpellier Santé Orale and similar studies have been conducted for nurses, speech therapists, physiotherapists, pharmacists, pediatricians, and medical general practitioners (GPs).

## Sample and setting

Two local midwifery associations sent out the questionnaire by email and social media networks to all registered midwives and practicing in the department of Herault (n=613), between April and May 2022. A purposive sampling technique was used and informed consent was obtained from all participants.

The protocol and study design were approved by ethics and regulatory agencies and were implemented in accordance with provisions of the Declaration of Helsinki. The appropriate Committee (Montpellier University Hospital Institutional Review Board, Montpellier, France) approved the protocol (IRB 2022_10_202201250).

Participants had to sign the informed consent. The informed consent form contained the name and affiliation of the investigator, a plain language description of the study, and the ethics committee approval.

## Data collection

The questionnaire (Supplementary file) was developed as part of a collaborative multidisciplinary project and was based on the one conducted in Australia¹⁰. It was distributed online using Google Forms.

The first part of our questionnaire was relevant to all healthcare professionals (including midwives, nurses, speech therapists, physiotherapists, pharmacists, pediatricians, and medical general practitioners), whereas the second part was specifically given to midwives.

The questionnaire integrated both quantitative and qualitative elements. It was divided into four sections. There were three question types: five open-ended questions, eight yes or no questions, and five multiple choice questions. The first section collected information about the survey respondent's background and training. The level of teaching was based on the declarative values and perceptions of the participants. The second section (14 questions) assessed their understanding of the relationship between oral health and general health. The third section (17 questions)

assessed the respondent's understanding of prevention, hygiene habits, and the role of food/drink in oral health. Lastly, the fourth section collected information about the respondent's knowledge of the relationship between pregnancy and oral health, approach during consultations and oral health prevention strategies preferences for themselves as well as with the general population.

## Data analysis

Incomplete questionnaires were excluded from the study. Microsoft Excel was used to perform the statistical analysis and the results are presented in percentages. Participants with missing data were excluded from any analyses involving that data. Data regarding the oral health knowledge and attitudes of midwives was summarized using descriptive statistics including frequencies, means and standard deviations. The Mann-Whitney U test was used to check whether there was a difference in correct responses, depending on the initial training. The significance threshold was set at 5%.

# RESULTS

## Participants

The total sample comprised 167 midwives. The response rate was 31.5% (n=193) but we excluded 26 questionnaires: midwives not practicing in the department of Herault, or incomplete questionnaires.

Most participants were female (98.8%), aged 24-62 years, with a mean of 37.3 ± 9.85 years. Most (53.9%) participants reported working in a hospital setting, 34.7% in private practice and 16.2% in private clinic, with some overlap between the groups since many participants had multiple professional practices. A range of levels of experience was reported, with participants stating that they had practiced midwifery between 1 to 41 years (mean=13.1 years). More than 75.0%, however, stated that they practiced for <20 years.

Most respondents (62.3%) completed their training in the department of Herault. Overall, only 30% of the participants said that they had taken an oral health module during their training, and only 13.2% expressed that they received adequate training.

We found that the midwives who had received their credentials more recently were more likely to have received training on oral health (Figure 1). Of the 13 participants (7.8%) who had received training on oral health since their qualification, all had qualified in or before 2007.

## Knowledge

For the questions on the relationship between oral health and general health, we received correct answers for 75.8% of the time (Table 1). The least correctly answered question was on whether oral bacteria can reach the amniotic fluid and lead to infections in expectant mothers (47.9% of participants answered this correctly), whereas the most correctly answered question was about tobacco use and that it increases the risk of upper respiratory tract cancer (98.2% of participants answered this correctly).
<figure><img src="image_5.png" /><figcaption>**Figure 1.** Proportion of midwives (n=167) who received training on oral health according to the number of years since their midwifery qualification, in the department of Herault in France (2022). The level of teaching was based on the declarative values and perceptions of the participants</figcaption></figure>

<figure><img src="image_6.png" /><figcaption>**Table 1.** Knowledge and attitudes of midwives on the relationship between oral health and general health, Herault, France, 2022 (N=167)</figcaption></figure>

<table><thead><tr><th rowspan="2">Statement</th><th rowspan="2">True/false</th><th colspan="2">Correct responses</th></tr><tr><th>n</th><th>%</th></tr></thead><tbody><tr><td>Studies show that there is little correlation between oral health and general health</td><td>False</td><td>154</td><td>92.2</td></tr><tr><td>Oral bacteria can spread through the organism via the blood and airways</td><td>True</td><td>145</td><td>86.8</td></tr><tr><td>Oral bacteria can reach the amniotic fluid and lead to infections in pregnant women</td><td>True</td><td>80</td><td>47.9</td></tr><tr><td>There is a bidirectional correlation between periodontal disease and diabetic control</td><td>True</td><td>92</td><td>55.1</td></tr><tr><td>Tobacco use increases the risk of upper respiratory tract cancer</td><td>True</td><td>164</td><td>98.2</td></tr><tr><td>There is an oral prevention examination 100% covered by Health Insurance from the 4th month of pregnancy</td><td>True</td><td>150</td><td>89.7</td></tr><tr><td>Dental care during pregnancy is limited to emergency care</td><td>False</td><td>149</td><td>89.2</td></tr><tr><td>The M'T Dents (prevention examination) concerns children from the age of 3 years</td><td>True</td><td>103</td><td>61.7</td></tr><tr><td>Oral bacteria can increase the risk of cardiovascular disease</td><td>True</td><td>104</td><td>62.3</td></tr><tr><td>Heredity can play a role in certain pathologies, but not for oral pathologies</td><td>False</td><td>154</td><td>92.2</td></tr><tr><td>The premature loss of baby teeth has no effect on permanent dentition</td><td>False</td><td>156</td><td>93.4</td></tr><tr><td>Respiratory problems in children can affect facial growth</td><td>True</td><td>95</td><td>56.9</td></tr><tr><td>The position of the tongue is an essential growth factor in skull development</td><td>True</td><td>113</td><td>67.7</td></tr><tr><td>Good oral health reduces the risk of lung disease</td><td>True</td><td>115</td><td>68.9</td></tr></tbody><tfoot><tr><td colspan="3"><strong>Total correct responses</strong></td><td><strong>75.8</strong></td></tr></tfoot></table>

Regarding the knowledge of midwives on food and drinks and their impact on caries prevention for their patients, we received correct responses for 74.7% of the time. The question that was correctly answered by all 167 respondents was on the products used by dentists for dental whitening

and whether they are similar to those found over the counter (Table 2). The two least correctly answered questions were about the reimbursement by the national health insurance (Assurance Maladie) and whether children aged <6 years could use fluoridated toothpaste.
<figure><img src="image_5.png" /><figcaption>**Figure 1.** Proportion of midwives (n=167) who received training on oral health according to the number of years since their midwifery qualification, in the department of Herault in France (2022). The level of teaching was based on the declarative values and perceptions of the participants</figcaption></figure>

<figure><img src="image_6.png" /><figcaption>**Table 1.** Knowledge and attitudes of midwives on the relationship between oral health and general health, Herault, France, 2022 (N=167)</figcaption></figure>

<table><thead><tr><th rowspan="2">Statement</th><th rowspan="2">True/false</th><th colspan="2">Correct responses</th></tr><tr><th>n</th><th>%</th></tr></thead><tbody><tr><td>Studies show that there is little correlation between oral health and general health</td><td>False</td><td>154</td><td>92.2</td></tr><tr><td>Oral bacteria can spread through the organism via the blood and airways</td><td>True</td><td>145</td><td>86.8</td></tr><tr><td>Oral bacteria can reach the amniotic fluid and lead to infections in pregnant women</td><td>True</td><td>80</td><td>47.9</td></tr><tr><td>There is a bidirectional correlation between periodontal disease and diabetic control</td><td>True</td><td>92</td><td>55.1</td></tr><tr><td>Tobacco use increases the risk of upper respiratory tract cancer</td><td>True</td><td>164</td><td>98.2</td></tr><tr><td>There is an oral prevention examination 100% covered by Health Insurance from the 4th month of pregnancy</td><td>True</td><td>150</td><td>89.7</td></tr><tr><td>Dental care during pregnancy is limited to emergency care</td><td>False</td><td>149</td><td>89.2</td></tr><tr><td>The M'T Dents (prevention examination) concerns children from the age of 3 years</td><td>True</td><td>103</td><td>61.7</td></tr><tr><td>Oral bacteria can increase the risk of cardiovascular disease</td><td>True</td><td>104</td><td>62.3</td></tr><tr><td>Heredity can play a role in certain pathologies, but not for oral pathologies</td><td>False</td><td>154</td><td>92.2</td></tr><tr><td>The premature loss of baby teeth has no effect on permanent dentition</td><td>False</td><td>156</td><td>93.4</td></tr><tr><td>Respiratory problems in children can affect facial growth</td><td>True</td><td>95</td><td>56.9</td></tr><tr><td>The position of the tongue is an essential growth factor in skull development</td><td>True</td><td>113</td><td>67.7</td></tr><tr><td>Good oral health reduces the risk of lung disease</td><td>True</td><td>115</td><td>68.9</td></tr></tbody><tfoot><tr><td><strong>Total correct responses</strong></td><td></td><td></td><td><strong>75.8</strong></td></tr></tfoot></table>

Regarding the knowledge of midwives on food and drinks and their impact on caries prevention for their patients, we received correct responses for 74.7% of the time. The question that was correctly answered by all 167 respondents was on the products used by dentists for dental whitening

and whether they are similar to those found over the counter (Table 2). The two least correctly answered questions were about the reimbursement by the national health insurance (Assurance Maladie) and whether children aged <6 years could use fluoridated toothpaste.
<figure><img src="image_7.png" /><figcaption>**Table 2.** Knowledge of midwives on food and drinks and their impact on caries prevention, Herault, France, 2022 (N=167)</figcaption></figure>

<table><caption>**Table 3.** Knowledge of midwives regarding oral health during pregnancy, Herault, France, 2022 (N=167)</caption><thead><tr><th rowspan="2">Statement</th><th rowspan="2">True/false</th><th colspan="2">Correct responses</th></tr><tr><th>n</th><th>%</th></tr></thead><tbody><tr><td>Brushing your teeth in the morning and at noon is equivalent to brushing your teeth in the morning and evening</td><td>False</td><td>165</td><td>98.8</td></tr><tr><td>An electric toothbrush is always more effective than a manual toothbrush, even if you use a good brushing technique</td><td>False</td><td>90</td><td>53.9</td></tr><tr><td>Toothbrushes with soft, medium or hard bristles are equally effective as long as the correct brushing technique is used</td><td>False</td><td>94</td><td>56.3</td></tr><tr><td>The number of bristles on a toothbrush influences the quality of brushing</td><td>True</td><td>81</td><td>48.5</td></tr><tr><td>A toothbrush with hard bristles can cause irreversible damage to the gum tissues as well as to the dental tissues</td><td>True</td><td>119</td><td>71.3</td></tr><tr><td>It is necessary to clean the interdental spaces with dental floss or interdental brushes daily in addition to the brushing</td><td>True</td><td>117</td><td>70.1</td></tr><tr><td>Mouth cleaning is no longer useful when you have no more teeth</td><td>False</td><td>166</td><td>99.4</td></tr><tr><td>Fluoride is a natural mineral that can be found in tap water, tea or some fish</td><td>True</td><td>90</td><td>53.9</td></tr><tr><td>For children under 6, toothpaste should not be fluoridated</td><td>False</td><td>83</td><td>49.7</td></tr><tr><td>Drinking sodas too often causes dental erosion</td><td>True</td><td>161</td><td>94.4</td></tr><tr><td>The products used by the dentist for dental whitening are similar to those found over the counter</td><td>False</td><td>167</td><td>100.0</td></tr><tr><td>The cleaning of dental prostheses (removable) can be done with a manual or electric toothbrush</td><td>False</td><td>97</td><td>58.1</td></tr><tr><td>It is not necessary to clean baby teeth as soon as they appear</td><td>False</td><td>160</td><td>95.8</td></tr><tr><td>Intake of sugary/acidic foods or drinks throughout the day increases the risk of developing caries</td><td>True</td><td>156</td><td>93.4</td></tr><tr><td>A 4-year-old child can has cavities because of drinking milk from a bottle (prolonged use of the bottle during the day or when falling asleep)</td><td>True</td><td>144</td><td>86.2</td></tr><tr><td>Risk of caries decreases when the quantity of saliva decreases</td><td>False</td><td>149</td><td>89.2</td></tr></tbody><tfoot><tr><td><strong>Total correct responses</strong></td><td></td><td></td><td><strong>74.7</strong></td></tr></tfoot></table>

<table><thead><tr><th rowspan="2">Statement</th><th rowspan="2">True/false</th><th colspan="2">Correct responses</th></tr><tr><th>n</th><th>%</th></tr></thead><tbody><tr><td>An oral pathology (periodontitis; caries, abscess) can cause a gynecological/obstetrics complication</td><td>True</td><td>146</td><td>87.4</td></tr><tr><td>Pregnant women are more susceptible to the development of periodontal disease than the average person</td><td>True</td><td>156</td><td>93.4</td></tr><tr><td>Maternal oral health status is related to child oral health status</td><td>True</td><td>46</td><td>27.5</td></tr></tbody><tfoot><tr><td><strong>Total correct responses</strong></td><td></td><td></td><td><strong>69.4</strong></td></tr></tfoot></table>

The least correctly answered questions were on those specifically regarding oral health during pregnancy (Table 3). These questions were only answered correctly 67.4% of the time. The least correctly answered question was whether maternal oral health status is related to child oral health status (27.5% of participants answered this correctly).

## Training

We did not find a correlation between the percentage of

correct responses and completion of training on oral health during initial training (Mann-Whitney test, p=0.4). The percentage of correct answers was 71.3% for participants without oral health module during their training and 75.8% for participants with the module.

There was also no difference found between the percentage of correct responses and having completed training considered 'adequate' (Mann-Whitney test, p=0.7). The percentage of correct answers was 76.3% for
<figure><img src="image_7.png" /><figcaption>**Table 2. Knowledge of midwives on food and drinks and their impact on caries prevention, Herault, France, 2022 (N=167)**</figcaption></figure>

<table><caption>**Table 3. Knowledge of midwives regarding oral health during pregnancy, Herault, France, 2022 (N=167)**</caption><thead><tr><th rowspan="2">Statement</th><th rowspan="2">True/false</th><th colspan="2">Correct responses</th></tr><tr><th>n</th><th>%</th></tr></thead><tbody><tr><td>Brushing your teeth in the morning and at noon is equivalent to brushing your teeth in the morning and evening</td><td>False</td><td>165</td><td>98.8</td></tr><tr><td>An electric toothbrush is always more effective than a manual toothbrush, even if you use a good brushing technique</td><td>False</td><td>90</td><td>53.9</td></tr><tr><td>Toothbrushes with soft, medium or hard bristles are equally effective as long as the correct brushing technique is used</td><td>False</td><td>94</td><td>56.3</td></tr><tr><td>The number of bristles on a toothbrush influences the quality of brushing</td><td>True</td><td>81</td><td>48.5</td></tr><tr><td>A toothbrush with hard bristles can cause irreversible damage to the gum tissues as well as to the dental tissues</td><td>True</td><td>119</td><td>71.3</td></tr><tr><td>It is necessary to clean the interdental spaces with dental floss or interdental brushes daily in addition to the brushing</td><td>True</td><td>117</td><td>70.1</td></tr><tr><td>Mouth cleaning is no longer useful when you have no more teeth</td><td>False</td><td>166</td><td>99.4</td></tr><tr><td>Fluoride is a natural mineral that can be found in tap water, tea or some fish</td><td>True</td><td>90</td><td>53.9</td></tr><tr><td>For children under 6, toothpaste should not be fluoridated</td><td>False</td><td>83</td><td>49.7</td></tr><tr><td>Drinking sodas too often causes dental erosion</td><td>True</td><td>161</td><td>94.4</td></tr><tr><td>The products used by the dentist for dental whitening are similar to those found over the counter</td><td>False</td><td>167</td><td>100.0</td></tr><tr><td>The cleaning of dental prostheses (removable) can be done with a manual or electric toothbrush</td><td>False</td><td>97</td><td>58.1</td></tr><tr><td>It is not necessary to clean baby teeth as soon as they appear</td><td>False</td><td>160</td><td>95.8</td></tr><tr><td>Intake of sugary/acidic foods or drinks throughout the day increases the risk of developing caries</td><td>True</td><td>156</td><td>93.4</td></tr><tr><td>A 4-year-old child can has cavities because of drinking milk from a bottle (prolonged use of the bottle during the day or when falling asleep)</td><td>True</td><td>144</td><td>86.2</td></tr><tr><td>Risk of caries decreases when the quantity of saliva decreases</td><td>False</td><td>149</td><td>89.2</td></tr></tbody><tfoot><tr><td><strong>Total correct responses</strong></td><td></td><td></td><td><strong>74.7</strong></td></tr></tfoot></table>

<table><thead><tr><th rowspan="2">Statement</th><th rowspan="2">True/false</th><th colspan="2">Correct responses</th></tr><tr><th>n</th><th>%</th></tr></thead><tbody><tr><td>An oral pathology (periodontitis; caries, abscess) can cause a gynecological/obstetrics complication</td><td>True</td><td>146</td><td>87.4</td></tr><tr><td>Pregnant women are more susceptible to the development of periodontal disease than the average person</td><td>True</td><td>156</td><td>93.4</td></tr><tr><td>Maternal oral health status is related to child oral health status</td><td>True</td><td>46</td><td>27.5</td></tr></tbody><tfoot><tr><td><strong>Total correct responses</strong></td><td></td><td></td><td><strong>69.4</strong></td></tr></tfoot></table>

The least correctly answered questions were on those specifically regarding oral health during pregnancy (Table 3). These questions were only answered correctly 67.4% of the time. The least correctly answered question was whether maternal oral health status is related to child oral health status (27.5% of participants answered this correctly).

## Training

We did not find a correlation between the percentage of

correct responses and completion of training on oral health during initial training (Mann-Whitney test, p=0.4). The percentage of correct answers was 71.3% for participants without oral health module during their training and 75.8% for participants with the module.

There was also no difference found between the percentage of correct responses and having completed training considered 'adequate' (Mann-Whitney test, p=0.7). The percentage of correct answers was 76.3% for
<figure><img src="image_8.png" /><figcaption>**Table 4.** Oral health prevention strategies for midwives and the general population, Hérault, France, 2022 (N=167)</figcaption></figure>

<table><thead><tr><th>Actions for distributing information on oral health</th><th>Midwives %</th><th>General population %</th></tr></thead><tbody><tr><td>Preventative action</td><td>-</td><td>43.1</td></tr><tr><td>Multidisciplinary meetings</td><td>31.7</td><td>-</td></tr><tr><td>Online training</td><td>21.0</td><td>-</td></tr><tr><td>Digital platform</td><td>20.4</td><td>4.2</td></tr><tr><td>Video clips</td><td>16.2</td><td>27.5</td></tr><tr><td>Flyers</td><td>-</td><td>13.8</td></tr><tr><td>Text messages</td><td>3.5</td><td>9.6</td></tr><tr><td>Books/magazines</td><td>4.2</td><td>1.8</td></tr><tr><td>Continuous training/university diploma</td><td>3.0</td><td>-</td></tr></tbody></table>

participants declaring their oral health module insufficient and 75.2% for those declaring the module sufficient.

Many participants expressed the feeling that they had not received adequate training on oral health during their training. One midwife who graduated in 2015 stated: 'During my training, we vaguely learned that there could be risks associated with the mother's oral health, but no more detail than that'. Another participant who graduated their training in 2014 specified: 'with this questionnaire, we realize how much we don't know about the subject'.

Moreover, 70.1% reported to have never received an oral health module during their initial training; and for those who received it, 65.2% reported that it was insufficient. To remedy this, participants provided suggestions: 1) to have interdisciplinary exchanges within their initial training and beyond, 2) to create a manual for midwives containing key information, and 3) create training courses for all healthcare professionals.

## Attitudes

Most participants (70.7%) reported that they do not provide information about oral health during their consultations and that it is primarily due to a lack of knowledge on the subject (41.9%). Additionally, 76.6% of respondents stated that no printed information about oral health during pregnancy was provided to the expectant mothers that they assisted.

In the free text responses, participants mentioned that some dentists refused to see or treat pregnant patients.

## Prevention

The ways in which information on oral health could be taught to midwives and the general population varied (Table 4). Our results showed that midwives had a preference for multidisciplinary meetings (31.7%), followed by online training (21%), digital platform (20.4%), video clips (16.2%), books/magazines (4.2%), text messages (3.5%) and continuous training/university diploma (3%).

In contrast, for educating the general population in oral health, the midwives favored preventive action (43.1%) followed by video clips (27.5%), distribution of flyers (13.8%), text messages (9.6%), digital platform (4.2%) and books/magazines (1.8%).

Many comments referred to the need to improve prevention campaigns for the general population. One participant suggested raising awareness among politicians, while another suggested placing posters in waiting rooms. Some participants mentioned a lack of clarity in the information given by the French health insurance system about dental examinations from the fourth month of pregnancy.

## DISCUSSION

This study revealed that few midwives, in the department of Hérault region, received specific training on oral health, and that there were gaps in their knowledge on oral health. We found similar results on the lack of education on oral health⁸⁻¹⁴. This may suggest that the lack of education and training on oral health for midwives is not isolated in Hérault alone. It is also worth noting that we observed that the midwives who had received their credentials more recently had more often received training on oral health, which suggests that there has been recognition of the importance of training midwives about this subject¹⁵. However, no significance was found in the number of correct responses between those who had or had not received training. This suggests that even when training is provided, it may be inadequate and corresponds with the midwives' own assessment in which less than half of those who had received training believed it to be adequate.

Regarding the participant characteristics, our findings were similar to the national statistics of midwives provided by the French government¹⁶. In 2021, France had 23400 midwives with an average age of 41 years for women and 36 years for men. Moreover, it was reported that 59% of midwives are employees and hospital workers, 34% of midwives are self-employed, 31% of midwives are in mixed practice, and 7% of midwives are classified as other.

A good understanding of the relationship between oral health and general health was stated among the participants. However, there were gaps in knowledge. Only 55.1% were aware of the bidirectional relationship between gum disease and diabetes. More generally, this concept seems to be poorly understood within the field. A study of French obstetrician-gynecologists (OB-GYNs) found that only 42.1% considered diabetes to be a risk factor in gum disease¹⁷. Similarly, prevention of oral health problems in relation to food and drink was observed. Midwives showed a good overall understanding; however, there were gaps in their knowledge.

Only 27.5% of participants from our present study knew that maternal oral health is related to the child's oral health. This is very low compared to the literature, in which 86.2% of midwives agreed with the same statement in the USA as did 62.1% of midwives in Australia⁸,¹⁰. In future work, it
<figure><img src="image_8.png" /><figcaption>**Table 4.** Oral health prevention strategies for midwives and the general population, Hérault, France, 2022 (N=167)</figcaption></figure>

<table><thead><tr><th>Actions for distributing information on oral health</th><th>Midwives %</th><th>General population %</th></tr></thead><tbody><tr><td>Preventative action</td><td>-</td><td>43.1</td></tr><tr><td>Multidisciplinary meetings</td><td>31.7</td><td>-</td></tr><tr><td>Online training</td><td>21.0</td><td>-</td></tr><tr><td>Digital platform</td><td>20.4</td><td>4.2</td></tr><tr><td>Video clips</td><td>16.2</td><td>27.5</td></tr><tr><td>Flyers</td><td>-</td><td>13.8</td></tr><tr><td>Text messages</td><td>3.5</td><td>9.6</td></tr><tr><td>Books/magazines</td><td>4.2</td><td>1.8</td></tr><tr><td>Continuous training/university diploma</td><td>3.0</td><td>-</td></tr></tbody></table>

participants declaring their oral health module insufficient and 75.2% for those declaring the module sufficient.

Many participants expressed the feeling that they had not received adequate training on oral health during their training. One midwife who graduated in 2015 stated: 'During my training, we vaguely learned that there could be risks associated with the mother's oral health, but no more detail than that'. Another participant who graduated their training in 2014 specified: 'with this questionnaire, we realize how much we don't know about the subject'.

Moreover, 70.1% reported to have never received an oral health module during their initial training; and for those who received it, 65.2% reported that it was insufficient. To remedy this, participants provided suggestions: 1) to have interdisciplinary exchanges within their initial training and beyond, 2) to create a manual for midwives containing key information, and 3) create training courses for all healthcare professionals.

## Attitudes

Most participants (70.7%) reported that they do not provide information about oral health during their consultations and that it is primarily due to a lack of knowledge on the subject (41.9%). Additionally, 76.6% of respondents stated that no printed information about oral health during pregnancy was provided to the expectant mothers that they assisted.

In the free text responses, participants mentioned that some dentists refused to see or treat pregnant patients.

## Prevention

The ways in which information on oral health could be taught to midwives and the general population varied (Table 4). Our results showed that midwives had a preference for multidisciplinary meetings (31.7%), followed by online training (21%), digital platform (20.4%), video clips (16.2%), books/magazines (4.2%), text messages (3.5%) and continuous training/university diploma (3%).

In contrast, for educating the general population in oral health, the midwives favored preventive action (43.1%) followed by video clips (27.5%), distribution of flyers (13.8%), text messages (9.6%), digital platform (4.2%) and books/magazines (1.8%).

Many comments referred to the need to improve prevention campaigns for the general population. One participant suggested raising awareness among politicians, while another suggested placing posters in waiting rooms. Some participants mentioned a lack of clarity in the information given by the French health insurance system about dental examinations from the fourth month of pregnancy.

## DISCUSSION

This study revealed that few midwives, in the department of Hérault region, received specific training on oral health, and that there were gaps in their knowledge on oral health. We found similar results on the lack of education on oral health⁸⁻¹⁴. This may suggest that the lack of education and training on oral health for midwives is not isolated in Hérault alone. It is also worth noting that we observed that the midwives who had received their credentials more recently had more often received training on oral health, which suggests that there has been recognition of the importance of training midwives about this subject¹⁵. However, no significance was found in the number of correct responses between those who had or had not received training. This suggests that even when training is provided, it may be inadequate and corresponds with the midwives' own assessment in which less than half of those who had received training believed it to be adequate.

Regarding the participant characteristics, our findings were similar to the national statistics of midwives provided by the French government¹⁶. In 2021, France had 23400 midwives with an average age of 41 years for women and 36 years for men. Moreover, it was reported that 59% of midwives are employees and hospital workers, 34% of midwives are self-employed, 31% of midwives are in mixed practice, and 7% of midwives are classified as other.

A good understanding of the relationship between oral health and general health was stated among the participants. However, there were gaps in knowledge. Only 55.1% were aware of the bidirectional relationship between gum disease and diabetes. More generally, this concept seems to be poorly understood within the field. A study of French obstetrician-gynecologists (OB-GYNs) found that only 42.1% considered diabetes to be a risk factor in gum disease¹⁷. Similarly, prevention of oral health problems in relation to food and drink was observed. Midwives showed a good overall understanding; however, there were gaps in their knowledge.

Only 27.5% of participants from our present study knew that maternal oral health is related to the child's oral health. This is very low compared to the literature, in which 86.2% of midwives agreed with the same statement in the USA as did 62.1% of midwives in Australia⁸,¹⁰. In future work, it
<figure><img src="image_9.png" /></figure>

could be worth considering the different training methods used and whether they could be applicable in France. For example, the New York State Department of Health edited a decisional tree to guide prenatal care providers and identify patients who require oral health¹⁸.

Although, integrating oral health into the midwifery curricula is still an issue, interprofessional training could be the key to strengthening the link between dentists and other healthcare providers. The objective would be to increase medical knowledge and therefore be more effective on giving holistic care, including oral care.

In 2010, the French health authority (Haute Autorité de Santé, HAS) stated that healthcare professionals working with expecting parents should receive training to give oral health advice relevant to parents and the child. The HAS also recommended that the subject of oral health should be discussed during midwifery consultations in the fourth month of pregnancy which matched with the knowledge of some participants free-text responses in our findings¹⁹.

In two previous research works, 80% of midwives consider themselves to be particularly well placed to discuss oral health prevention with the expectant mothers they cared for and that midwives have a key role to play⁷,¹⁴.

In our study, less than a third of the participants provided information about oral health to their patients, although it should be noted that for some, notably those working in emergency obstetric care, this question did not seem relevant. This was similar to a French study conducted on OB/GYNs which reported that only 26.3% of them discussed oral health with their pregnant patients¹⁷. This lack of willingness to broach the subject with patients could be due to a lack of knowledge. Nearly half (41.9%) of our participants stated this as their reason, and more than two-thirds of the participants in the Australian study felt that they did not have enough knowledge to give oral health advice¹⁰. Additionally, in a recent study of midwives in Brittany, France, 88.8% reported 'insufficient' or 'non-existent' knowledge about the link between oral health and pregnancy. Most (85.4%) addressed the topic of oral health 'never' or 'sometimes'. In line with the results of our study, very few of these midwives had received training on oral health during their initial studies, and the vast majority reported an interest in receiving more training²⁰. These results suggest that our observations are part of a wider trend throughout France.

Together, these results highlight that if the HAS recommendations are to be met, a significant improvement in oral health education and confidence-building among midwives need to be achieved. In addition to improving oral health education during midwifery training programs, the lack of knowledge, revealed in our study, highlights the possible need of improving awareness among already practicing midwives and the general population.

In terms of communication with healthcare professionals, participants showed a preference for the creation of a digital resource platform. A well-designed, easy-to-use interface could offer helpful resources for midwives and other healthcare professionals. The midwives we surveyed were

also interested in multidisciplinary events that have already been shown to improve interdisciplinary understanding and communication²¹. The third most popular option was online training. An Australian study has shown the effectiveness of a self-directed online training course for midwives in that it found they helped midwives to integrate oral health promotion into their clinical practice²².

To confirm the interest of the use of digital technology to reach healthcare professionals, it may be worth noting that the WHO launched the mOralHealth Programme and the Handbook on 'Mobile technologies for oral health: An implementation guide' in 2021²³. The program proposes a specific module on mOralHealth training to improve knowledge and skills of frontline health workers on oral health including midwives.

A systematic review, conducted in 2018, demonstrated the effectiveness of educational programs about oral health for the general population²⁴. The most popular method among the midwives we surveyed was in-person interaction followed by video clips. The use of the email and social media has also been shown to be effective in communicating oral health information to the general population particularly in the form of training courses²⁵. This should be taken into consideration when thinking about prevention campaigns. Text messages were less popular among our study population, but a study conducted in Iran, showed them to be an effective way of improving knowledge and attitude among pregnant women²⁶. Similarly, the creation of a digital platform was not popular in our study, but has been shown to have a positive effect on knowledge and attitudes²⁷. This raises the possibility that the methods preferred by the midwives are not necessarily the most effective in practice. The relative effectiveness of different communication strategies is therefore an important area for future research. It would be interesting to compare our results to the results obtained using the same base questionnaire with different healthcare professionals. This could reveal ways in which they could collaborate on informational content and/or prevention campaigns, for example, shared digital platforms or training courses.

## Limitations

Regarding the limitations, it was a pilot study with a small participant number and the use of the email. Also, email and social media networks to disseminate the questionnaire may have led to a potential selection bias towards a younger population. Additionally, the voluntary nature of the study means that the respondents were likely to be more interested in the topic compared to their colleagues who did not respond. It should also be noted that the structure of the questionnaire (providing statements to be marked true/false by the respondent) may have triggered some participants' subject-specific memories that might not have otherwise been recalled.

## CONCLUSIONS

Despite increased attention on oral health education during midwife training, our study shows that midwives lack the
<figure><img src="image_9.png" /></figure>

could be worth considering the different training methods used and whether they could be applicable in France. For example, the New York State Department of Health edited a decisional tree to guide prenatal care providers and identify patients who require oral health¹⁸.

Although, integrating oral health into the midwifery curricula is still an issue, interprofessional training could be the key to strengthening the link between dentists and other healthcare providers. The objective would be to increase medical knowledge and therefore be more effective on giving holistic care, including oral care.

In 2010, the French health authority (Haute Autorité de Santé, HAS) stated that healthcare professionals working with expecting parents should receive training to give oral health advice relevant to parents and the child. The HAS also recommended that the subject of oral health should be discussed during midwifery consultations in the fourth month of pregnancy which matched with the knowledge of some participants free-text responses in our findings¹⁹.

In two previous research works, 80% of midwives consider themselves to be particularly well placed to discuss oral health prevention with the expectant mothers they cared for and that midwives have a key role to play⁷,¹⁴.

In our study, less than a third of the participants provided information about oral health to their patients, although it should be noted that for some, notably those working in emergency obstetric care, this question did not seem relevant. This was similar to a French study conducted on OB/GYNs which reported that only 26.3% of them discussed oral health with their pregnant patients¹⁷. This lack of willingness to broach the subject with patients could be due to a lack of knowledge. Nearly half (41.9%) of our participants stated this as their reason, and more than two-thirds of the participants in the Australian study felt that they did not have enough knowledge to give oral health advice¹⁰. Additionally, in a recent study of midwives in Brittany, France, 88.8% reported ‘insufficient’ or ‘non-existent’ knowledge about the link between oral health and pregnancy. Most (85.4%) addressed the topic of oral health ‘never’ or ‘sometimes’. In line with the results of our study, very few of these midwives had received training on oral health during their initial studies, and the vast majority reported an interest in receiving more training²⁰. These results suggest that our observations are part of a wider trend throughout France.

Together, these results highlight that if the HAS recommendations are to be met, a significant improvement in oral health education and confidence-building among midwives need to be achieved. In addition to improving oral health education during midwifery training programs, the lack of knowledge, revealed in our study, highlights the possible need of improving awareness among already practicing midwives and the general population.

In terms of communication with healthcare professionals, participants showed a preference for the creation of a digital resource platform. A well-designed, easy-to-use interface could offer helpful resources for midwives and other healthcare professionals. The midwives we surveyed were

also interested in multidisciplinary events that have already been shown to improve interdisciplinary understanding and communication²¹. The third most popular option was online training. An Australian study has shown the effectiveness of a self-directed online training course for midwives in that it found they helped midwives to integrate oral health promotion into their clinical practice²².

To confirm the interest of the use of digital technology to reach healthcare professionals, it may be worth noting that the WHO launched the mOralHealth Programme and the Handbook on ‘Mobile technologies for oral health: An implementation guide’ in 2021²³. The program proposes a specific module on mOralHealth training to improve knowledge and skills of frontline health workers on oral health including midwives.

A systematic review, conducted in 2018, demonstrated the effectiveness of educational programs about oral health for the general population²⁴. The most popular method among the midwives we surveyed was in-person interaction followed by video clips. The use of the email and social media has also been shown to be effective in communicating oral health information to the general population particularly in the form of training courses²⁵. This should be taken into consideration when thinking about prevention campaigns. Text messages were less popular among our study population, but a study conducted in Iran, showed them to be an effective way of improving knowledge and attitude among pregnant women²⁶. Similarly, the creation of a digital platform was not popular in our study, but has been shown to have a positive effect on knowledge and attitudes²⁷. This raises the possibility that the methods preferred by the midwives are not necessarily the most effective in practice. The relative effectiveness of different communication strategies is therefore an important area for future research. It would be interesting to compare our results to the results obtained using the same base questionnaire with different healthcare professionals. This could reveal ways in which they could collaborate on informational content and/or prevention campaigns, for example, shared digital platforms or training courses.

## Limitations

Regarding the limitations, it was a pilot study with a small participant number and the use of the email. Also, email and social media networks to disseminate the questionnaire may have led to a potential selection bias towards a younger population. Additionally, the voluntary nature of the study means that the respondents were likely to be more interested in the topic compared to their colleagues who did not respond. It should also be noted that the structure of the questionnaire (providing statements to be marked true/false by the respondent) may have triggered some participants’ subject-specific memories that might not have otherwise been recalled.

## CONCLUSIONS

Despite increased attention on oral health education during midwife training, our study shows that midwives lack the
<figure><img src="image_10.png" /></figure>

required knowledge to fulfil this role. Systematic inclusion
of an oral health curriculum in initial training could help
to bridge this gap as could awareness and prevention
campaigns for both midwives and for the general population.
Future research should assess the most effective methods
to employ.

REFERENCES

1. Fiorillo L. Oral Health: The First Step to Well-Being. Medicina (Kaunas). 2019;55(10):676. doi:10.3390/medicina55100676

2. Global oral health status report: Towards universal health coverage for oral health by 2030. World Health Organization. Accessed March 12, 2023. https://www.who.int/team/noncommunicablediseases/global-status-report-on-oral-health-2022

3. World Health Organization. ORAL HEALTH COUNTRY PROFILE. France. WHO; 2022. Accessed March 12, 2023. https://cdn.who.int/media/docs/default-source/country-profiles/oral-health/oral-health-fra-2022-country-profile.pdf?sfvrsn=c79a2253_5&download=true

4. Yousefi M, Parvaie P, Riahi SM. Salivary factors related to caries in pregnancy: A systematic review and meta-analysis. J Am Dent Assoc. 2020;151(8):576-588.e4. doi:10.1016/j.aime.2020.04.021

5. Dye BA, Vargas CM, Lee JJ, Magder L, Tinanoff N. Assessing the relationship between children's oral health status and that of their mothers. J Am Dent Assoc. 2011;142(2):173-183. doi:10.14219/jada.archive.2011.0061

6. Raju K, Berens L. Periodontology and pregnancy: An overview of biomedical and epidemiological evidence. Periodontol 2000. 2021;87(1):132-142. doi:10.1111/prd.12394

7. Hellyer P. Midwives have a role to play in oral health education. Br Dent J. 2020;228(9):686. doi:10.1038/s41415-020-1616-5

8. Naavaal S, Claiborne DM. Oral Health Knowledge, Practices, and Awareness of Oral Health Guidelines and Dental Coverage Policies among Midwives. J Midwifery Womens Health. 2021;66(1):88-95. doi:10.1111/jmwh.13191

9. Hoerler SB, Jenkins S, Assad D. Evaluating Oral Health in Pregnant Women: Knowledge, attitudes and practices of health professionals. J Dent Hyg. 2019;93(1):16-22. Accessed September 19, 2023. https://jdh.adha.org/content/jdenthyg/93/1/16.full.pdf

10. George A, Dahlen HG, Reath J, et al. What do antenatal care providers understand and do about oral health care during pregnancy: a cross-sectional survey in New South Wales, Australia. BMC Pregnancy Childbirth. 2016;16(1):382. doi:10.1186/s12884-016-1163-x

11. Nguyen JG, Nanayakkara S, Holden ACL. Knowledge, Attitudes and Practice Behaviour of Midwives Concerning Periodontal Health of Pregnant Patients. Int J Environ Res Public Health. 2020;17(7):2246. doi:10.3390/ijerph17072246

12. Touriño S, Suárez-Cotelo MdC, Núñez-Iglesias MJ, et al. Knowledge, Attitudes, and Practices of Spanish Midwives and Midwifery Students toward Oral Healthcare during Pregnancy. Int J Environ Res Public Health. 2021;18(11):6089. doi:10.3390/ijerph18116089

13. Wagner Y, Heinrich-Weltzien R. Midwives' oral health recommendations for pregnant women, infants and young children: results of a nationwide survey in Germany. BMC Oral Health. 2016;16:36. doi:10.1186/s12903-016-0192-1

14. Boutigny H, de Moegen ML, Egea L, et al. Oral Infections and Pregnancy: Knowledge of Gynecologists/ Obstetricians, Midwives and Dentists. Oral Health Prev Dent. 2016;14(1):41-47. doi:10.3290/j.ohpd.a34376

15. Bhagat V, Hoang H, Crocombe LA, Goldberg LR. Incorporating oral health care education in undergraduate nursing curricula - a systematic review. BMC Nurs. 2020;19:66. doi:10.1186/s12912-020-00454-6

16. Démographie des professionnels de santé. Direction de la recherche, des études, de l'évaluation et des statistiques. Accessed March 12, 2023. https://drees.shinyapps.io/demographie-ps/

17. Cohen L, Schaeffer M, Davideau JL, Tenenbaum H, Huck O. Obstetric Knowledge, Attitude, and Behavior Concerning Periodontal Diseases and Treatment Needs in Pregnancy: Influencing Factors in France. J Periodontol. 2015;86(3):398-405. doi:10.1902/jop.2014.140371

18. Oral Health Care during Pregnancy and Early Childhood Practice Guidelines. New York State Department of Health; 2006. Accessed March 12, 2023. https://www.health.ny.gov/publications/0824.pdf

19. Stratégies de prévention de la carie dentaire: Synthèse et Recommandations. Haute Autorité de Santé; 2010. Accessed March 12, 2023. https://www.has-sante.fr/upload/docs/application/pdf/2010-10/corriges Synthese carie dentaire version postcollege-10sept2010.pdf

20. Novello S, Pailleau M, Le Dévéhat P, Jeanne S. Periodontal Diseases and Pregnancy: Knowledge and Clinical Practice Habits of French Midwives. Oral Health and Prev Dent. 2022;20(1):525-532. doi:10.3290/j.ohpd.b3680323

21. Duley SI, Fitzpatrick PG, Zornosa X, Gail Barnes W. A Center for Oral Health Promotion: Establishing an Inter-Professional Paradigm for Dental Hygiene, Health Care Management and Nursing Education. J Dent Hyg. 2012;86(2):63-70. Accessed September 19, 2023. https://jdh.adha.org/content/jdenthyg/86/2/63.full.pdf

22. George A, Duff M, Ajwani S, et al. Development of an Online Education Program for Midwives in Australia to Improve Perinatal Oral Health. J Perinat Educ. 2012;21(2):112-122. doi:10.1891/1058-1243.21.2.112

23. World Health Organization and International Telecommunication Union. Mobile technologies for oral health: an implementation guide. World Health
<figure><img src="image_10.png" /></figure>

required knowledge to fulfil this role. Systematic inclusion
of an oral health curriculum in initial training could help
to bridge this gap as could awareness and prevention
campaigns for both midwives and for the general population.
Future research should assess the most effective methods
to employ.

REFERENCES

1. Fiorillo L. Oral Health: The First Step to Well-Being. Medicina (Kaunas). 2019;55(10):676. doi:10.3390/medicina55100676

2. Global oral health status report: Towards universal health coverage for oral health by 2030. World Health Organization. Accessed March 12, 2023. https://www.who.int/team/noncommunicablediseases/global-status-report-on-oral-health-2022

3. World Health Organization. ORAL HEALTH COUNTRY PROFILE. France. WHO; 2022. Accessed March 12, 2023. https://cdn.who.int/media/docs/default-source/country-profiles/oral-health/oral-health-fra-2022-country-profile.pdf?sfvrsn=c79a2253_5&download=true

4. Yousefi M, Parvaie P, Riahi SM. Salivary factors related to caries in pregnancy: A systematic review and meta-analysis. J Am Dent Assoc. 2020;151(8):576-588.e4. doi:10.1016/j.aime.2020.04.021

5. Dye BA, Vargas CM, Lee JJ, Magder L, Tinanoff N. Assessing the relationship between children's oral health status and that of their mothers. J Am Dent Assoc. 2011;142(2):173-183. doi:10.14219/jada.archive.2011.0061

6. Raju K, Berens L. Periodontology and pregnancy: An overview of biomedical and epidemiological evidence. Periodontol 2000. 2021;87(1):132-142. doi:10.1111/prd.12394

7. Hellyer P. Midwives have a role to play in oral health education. Br Dent J. 2020;228(9):686. doi:10.1038/s41415-020-1616-5

8. Naavaal S, Claiborne DM. Oral Health Knowledge, Practices, and Awareness of Oral Health Guidelines and Dental Coverage Policies among Midwives. J Midwifery Womens Health. 2021;66(1):88-95. doi:10.1111/jmwh.13191

9. Hoerler SB, Jenkins S, Assad D. Evaluating Oral Health in Pregnant Women: Knowledge, attitudes and practices of health professionals. J Dent Hyg. 2019;93(1):16-22. Accessed September 19, 2023. https://jdh.adha.org/content/jdenthyg/93/1/16.full.pdf

10. George A, Dahlen HG, Reath J, et al. What do antenatal care providers understand and do about oral health care during pregnancy: a cross-sectional survey in New South Wales, Australia. BMC Pregnancy Childbirth. 2016;16(1):382. doi:10.1186/s12884-016-1163-x

11. Nguyen JG, Nanayakkara S, Holden ACL. Knowledge, Attitudes and Practice Behaviour of Midwives Concerning Periodontal Health of Pregnant Patients. Int J Environ Res Public Health. 2020;17(7):2246. doi:10.3390/ijerph17072246

12. Touriño S, Suárez-Cotelo MdC, Núñez-Iglesias MJ, et al. Knowledge, Attitudes, and Practices of Spanish Midwives and Midwifery Students toward Oral Healthcare during Pregnancy. Int J Environ Res Public Health. 2021;18(11):6089. doi:10.3390/ijerph18116089

13. Wagner Y, Heinrich-Weltzien R. Midwives' oral health recommendations for pregnant women, infants and young children: results of a nationwide survey in Germany. BMC Oral Health. 2016;16:36. doi:10.1186/s12903-016-0192-1

14. Boutigny H, de Moegen ML, Egea L, et al. Oral Infections and Pregnancy: Knowledge of Gynecologists/ Obstetricians, Midwives and Dentists. Oral Health Prev Dent. 2016;14(1):41-47. doi:10.3290/j.ohpd.a34376

15. Bhagat V, Hoang H, Crocombe LA, Goldberg LR. Incorporating oral health care education in undergraduate nursing curricula - a systematic review. BMC Nurs. 2020;19:66. doi:10.1186/s12912-020-00454-6

16. Démographie des professionnels de santé. Direction de la recherche, des études, de l'évaluation et des statistiques. Accessed March 12, 2023. https://drees.shinyapps.io/demographie-ps/

17. Cohen L, Schaeffer M, Davideau JL, Tenenbaum H, Huck O. Obstetric Knowledge, Attitude, and Behavior Concerning Periodontal Diseases and Treatment Needs in Pregnancy: Influencing Factors in France. J Periodontol. 2015;86(3):398-405. doi:10.1902/jop.2014.140371

18. Oral Health Care during Pregnancy and Early Childhood Practice Guidelines. New York State Department of Health; 2006. Accessed March 12, 2023. https://www.health.ny.gov/publications/0824.pdf

19. Stratégies de prévention de la carie dentaire: Synthèse et Recommandations. Haute Autorité de Santé; 2010. Accessed March 12, 2023. https://www.has-sante.fr/upload/docs/application/pdf/2010-10/corriges Synthese carie dentaire version postcollege-10sept2010.pdf

20. Novello S, Pailleau M, Le Dévéhat P, Jeanne S. Periodontal Diseases and Pregnancy: Knowledge and Clinical Practice Habits of French Midwives. Oral Health and Prev Dent. 2022;20(1):525-532. doi:10.3290/j.ohpd.b3680323

21. Duley SI, Fitzpatrick PG, Zornosa X, Gail Barnes W. A Center for Oral Health Promotion: Establishing an Inter-Professional Paradigm for Dental Hygiene, Health Care Management and Nursing Education. J Dent Hyg. 2012;86(2):63-70. Accessed September 19, 2023. https://jdh.adha.org/content/jdenthyg/86/2/63.full.pdf

22. George A, Duff M, Ajwani S, et al. Development of an Online Education Program for Midwives in Australia to Improve Perinatal Oral Health. J Perinat Educ. 2012;21(2):112-122. doi:10.1891/1058-1243.21.2.112

23. World Health Organization and International Telecommunication Union. Mobile technologies for oral health: an implementation guide. World Health
<figure><img src="image_11.png" /></figure>

Organization; 2021. Accessed March 12, 2023.
https://apps.who.int/iris/handle/10665/345255

24. Ghaffari M, Rakhshanderou S, Ramezankhani A, Buunk-Werkhoven YAB, Noroozi M, Armoon B. Are educating and promoting interventions effective in oral health?: A systematic review. Int J Dent Hyg. 2018;16(1):48-58.
doi:10.1111/idh.12305

25. George A, Kong AC, Villarosa A, et al. Implementing and evaluating the effectiveness of an oral health module for the bachelor of midwifery program at an Australian university. Nurse Educ Today. 2020;90:104457.
doi:10.1016/j.nedt.2020.104457

26. Divdar M, Araban M, Heydarabadi AB, Cheraghian B, Stein LAR. Effectiveness of message-framing to improve oral health behaviors and dental plaque among pregnant women. Arch Public Health. 2021;79(1):117.
doi:10.1186/s13690-021-00640-1

27. Mariño RJ, Marwaha P, Barrow SY. Web-based oral health promotion program for older adults: Development and preliminary evaluation. Int J Med Inform. 2016;91:e9-e15.
doi:10.1016/j.ijmedinf.2016.04.002

**CONFLICTS OF INTEREST**

The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none was reported.

**FUNDING**

There was no source of funding for this research.

**ETHICAL APPROVAL AND INFORMED CONSENT**

Ethical approval was obtained from the Institutional Review Board of Montpellier University Hospital, Montpellier, France (Approval number: IRB 2022_10_202201250; Date: 20 October 2022). Participants provided informed consent.

**DATA AVAILABILITY**

All anonymized data are available from the corresponding author upon reasonable request.

**PROVENANCE AND PEER REVIEW**

Not commissioned; externally peer reviewed.
<figure><img src="image_11.png" /></figure>

Organization; 2021. Accessed March 12, 2023.
https://apps.who.int/iris/handle/10665/345255

24. Ghaffari M, Rakhshanderou S, Ramezankhani A, Buunk-Werkhoven YAB, Noroozi M, Armoon B. Are educating and promoting interventions effective in oral health?: A systematic review. Int J Dent Hyg. 2018;16(1):48-58.
doi:10.1111/idh.12305

25. George A, Kong AC, Villarosa A, et al. Implementing and evaluating the effectiveness of an oral health module for the bachelor of midwifery program at an Australian university. Nurse Educ Today. 2020;90:104457.
doi:10.1016/j.nedt.2020.104457

26. Divdar M, Araban M, Heydarabadi AB, Cheraghian B, Stein LAR. Effectiveness of message-framing to improve oral health behaviors and dental plaque among pregnant women. Arch Public Health. 2021;79(1):117.
doi:10.1186/s13690-021-00640-1

27. Mariño RJ, Marwaha P, Barrow SY. Web-based oral health promotion program for older adults: Development and preliminary evaluation. Int J Med Inform. 2016;91:e9-e15.
doi:10.1016/j.ijmedinf.2016.04.002

**CONFLICTS OF INTEREST**

The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none was reported.

**FUNDING**

There was no source of funding for this research.

**ETHICAL APPROVAL AND INFORMED CONSENT**

Ethical approval was obtained from the Institutional Review Board of Montpellier University Hospital, Montpellier, France (Approval number: IRB 2022_10_202201250; Date: 20 October 2022). Participants provided informed consent.

**DATA AVAILABILITY**

All anonymized data are available from the corresponding author upon reasonable request.

**PROVENANCE AND PEER REVIEW**

Not commissioned; externally peer reviewed.