Incorporating basic periodontal screening into antenatal care services provided in Rwanda: A policy brief

Background Preterm birth, which is child delivery before 37 weeks of pregnancy, is the primary cause of perinatal mortality worldwide. Preterm birth remains a major public health challenge in Rwanda, affecting approximately 13.8% of birth. The World Health Organization estimates that 15 million babies are born prematurely each year. While the association between periodontitis and preterm deliveries is increasingly recognized, little is known about this link in Rwanda. This policy brief aims to bridge this knowledge gap by presenting the findings of a recent study investigating the prevalence of periodontitis among pregnant women in Rwanda and its association with preterm deliveries. This policy brief also aims to inform and guide decision making towards incorporating periodontal screening into the antenatal care package in Rwanda. This has the potential to improve pregnancy outcomes and contribute to improved oral health in the future. Policy outcome and Implications Contemporary evidence has shown a six-fold increased risk of preterm delivery for women with periodontitis in Rwanda, with a concerningly high prevalence (60%) among pregnant women. Additionally, nurses working in antenatal clinics displayed insufficient knowledge about gum disease. Actionable recommendations The adoption of basic periodontal screening within existing antenatal care packages is recommended. This, coupled with nurse training and public awareness campaigns, can empower women and healthcare professionals to prioritize oral health for better pregnancy outcomes. Conclusions Integrating periodontal screening into antenatal care has the potential to significantly reduce preterm deliveries and contribute to a healthier future generation in Rwanda.


Background
Preterm birth, which is child delivery before 37 weeks of pregnancy, is the primary cause of perinatal mortality worldwide and a risk factor for preterm delivery.2][3] The World Health Organization estimates that 15 million babies are born prematurely each year. 1 Periodontitis is a chronic inflammatory disease of the gums that can lead to tooth loss.It is one of the most common chronic diseases in the world, affecting nearly half of all adults. 4ile the association between periodontitis and preterm deliveries is increasingly recognized, little is known about this link in Rwanda.This policy brief aims to bridge this knowledge gap by presenting the findings of a recent study investigating the prevalence of periodontitis among pregnant women in Rwanda and its association with preterm deliveries.This policy brief also aims to inform and guide decision making towards incorporating periodontal screening into the antenatal care package in Rwanda.This has the potential to improve pregnancy outcomes and contribute to improved oral health in the future.

Policy outcomes and implications
Different studies have suggested a complex link between periodontitis and preterm birth.6][7][8] Also, oral bacteria from infected gums can reach the placenta and amniotic fluid, triggering an inflammatory response in the uterus and inducing preterm labor. 9,10Also, periodontitis can impair nutrient absorption, impacting fetal growth and development which may contribute to preterm birth. 11Periodontal diseases occur as result of dysbiosis in bacterial biofilm inhabiting the sulcus, below the gingival margin.Periodontal diseases are inclusive of the main diagnostic categories of periodontitis and gingivitis. 7,8,12isting research from Rwanda, like some other African countries, demonstrates a significant association between periodontitis and preterm birth.A study in Kenya reported that women with periodontitis have 2 times risk of giving birth to preterm babies than women without periodontitis. 13In Ethiopia, a study reported 2-4 times the odds of giving birth to preterm babies in women with periodontitis 14 while in Rwanda is six-fold risk of preterm in women with periodontitis than those with no periodontitis. 154][15] Further, research has also shown that nurses and midwives in Rwanda had insufficient knowledge on periodontitis. 16Therefore, there is a need for a tool to nurses and midwives in Rwanda in the detection of periodontal diseases among pregnant women during antenatal care consultations.
Periodontal screening is not currently part of the antenatal care package in Rwanda, despite the increasing prevalence of periodontitis among pregnant women in Rwanda.Research evidence has shown the strong association between periodontitis and preterm birth. 15[19][20][21] Antenatal care consultations constitute an important opportunity to perform screening for periodontitis during pregnancy in the context of Rwanda.Firstly, antenatal care consultations are mandatory for all pregnant women.Secondly, the uptake is high (98%) and a greater number of pregnant women meet the required number of antenatal care visits. 22e increasing uptake of antenatal care services in Rwanda is supported by more comprehensive medical insurance schemes (e.g "Mutuel de Sante" that covers 85% of the cost).Community health workers (CHWs) identify all pregnant women in their villages and follow them up until delivery.CHWs ensure that these pregnant women attend antenatal care.
Oral diseases, including periodontitis, are neglected and it is rare for a woman to go for dental check-ups unless when in pain.Antenatal care is an important platform that offers the opportunity to bring awareness on periodontitis during

REVISED Amendments from Version 1
The difference is that we addressed the comments given by reviewers where there were some typing errors, we corrected and we also added the new references as recommended.We have responded to the review reports at the end of each report.
Any further responses from the reviewers can be found at the end of the article pregnancy.Periodontitis screening during antenatal care consultations will facilitate the access of all pregnant women to oral health.
The development of a periodontal screening tool that can be utilized and integrated in an antenatal care package would therefore be desirable and cost-effective.Thus, this policy brief calls for the development of a screening tool as well as the sustainable implementation of such a tool.If a robust screening tool is successfully developed, then future studies may be conducted to explore the management of periodontitis during pregnancy and its effect on preterm delivery in Rwanda.

Actionable recommendations
To address the potential link between periodontitis and preterm birth in Rwanda, multiple recommendations are proposed.Some of these recommendations were raised during the policy engagement workshop that was held and led by the lead author of this policy brief, in October 2023, where there was a presentation of the study findings to different policy makers and partners that included professional associations, representatives from hospitals and representatives from Rwanda Ministry of Health through the Rwanda Biomedical Center.These recommendations are below: The incorporation of Periodontal Screening in Antenatal Care: There is a need to integrate a basic periodontal screening into the existing Rwandan ANC package.This screening can be performed by trained nurses and could involve visual inspection and probing to identify signs of gum inflammation and potential periodontitis.This can be done by developing clear protocols and guidelines for nurses on how to conduct the screening, interpret results, and refer women with suspected periodontitis to dentists for further evaluation and treatment.

Capacity Building for Nurses:
There is need to implement training programs to equip nurses working in antenatal clinics with the knowledge and skills to effectively: conduct basic periodontal screenings, educate pregnant women about oral hygiene practices and the link between gum health and pregnancy outcomes and advise women on appropriate referrals for periodontal treatment when necessary.
Public Awareness Campaigns: There is a need to develop and disseminate public awareness campaigns to educate women of childbearing age about periodontal disease, its risks during pregnancy, and the importance of maintaining good oral hygiene.

Conclusion
While the causal relationship between periodontitis and preterm birth requires further investigation, the existing evidence suggests a potentially significant link.By integrating oral health into maternal care, promoting oral hygiene practices, and conducting further research, we can take crucial steps to address this issue and improve maternal and child health outcomes in Rwanda.Policymakers, healthcare professionals, and community leaders in Rwanda should recognize the potential impact of periodontitis on preterm birth.By implementing the recommended actions and prioritizing oral health promotion, we can work together to ensure mothers and babies have a healthy start in life.

Policy outcomes and implications
Please check the wording in the last sentence of the first paragraph.
I suggest that the second paragraph focus on the association of periodontitis and preterm birth.
In the third paragraph the information on the association of periodontitis and preterm birth is unnecessary.Third paragraph, line 3 -" There is a need fora tool to support the nurses/midwives to detect periodontal diseases among pregnant women during antenatal care consultations.…"Please check the wording.

Actionable recommendations
First Response: Thank you.We have now cited these two references in the revised manuscript.
Reviewer 2-Background: I that sentences 1 and 6 in the first paragraph could be synthesized -the information is the same.
Response: Thank you.Both sentences have now been synthesized.

Reviewer 2-Policy outcomes and implications:
Please check the wording in the last sentence of the first paragraph.
Response: Thank you.This sentence has now been revised.
Reviewer 2: I suggest that the second paragraph focus on the association of periodontitis and preterm birth.In the third paragraph the information on the association of periodontitis and preterm birth is unnecessary.
Response: Thank you.This sentence, and paragraph, has now been revised.
Reviewer 2: Third paragraph, line 3 -" There is a need fora tool to support the nurses/midwives to detect periodontal diseases among pregnant women during antenatal care consultations.…"Please check the wording.
Response: Thank you.This sentence has now been revised.This is a brief policy brief on the issue of preterm births in Rwanda.It has been shown that the rate of these births is very high.Simultaneously, several studies have found periodontitis to be a risk factor for preterm birth (<37 weeks).The aim of this study is to assess the prevalence of periodontitis in the country and to recommend a social policy of periodontitis control in pregnant women: diagnosis and prenatal care to reduce it and decrease the incidence of preterm births.
Some objectives to be commented on: --In section "Policy outcomes and implications", 4th paragraph, last line, there is a reference to some studies but the citations of these studies are not given.They should be referenced.
its possible repercussions on the foeto-placental unit.
Response: Thank you.
REVIEWER 1: Perhaps I could suggest to the authors to add these three references as they are studies also carried out in East Africa.Response: Thank you.We have now cited these three references in the revised manuscript.
REVIEWER 1: This is a brief policy brief on the issue of preterm births in Rwanda.It has been shown that the rate of these births is very high.Simultaneously, several studies have found periodontitis to be a risk factor for preterm birth (<37 weeks).The aim of this study is to assess the prevalence of periodontitis in the country and to recommend a social policy of periodontitis control in pregnant women: diagnosis and prenatal care to reduce it and decrease the incidence of preterm births.
Some objectives to be commented on: --In section "Policy outcomes and implications", 4th paragraph, last line, there is a reference to some studies but the citations of these studies are not given.They should be referenced.
Response: Thank you.We have now provided references to support this sentence.We cited the three references you recommended as well as the two references recommended by Reviewer 2.
Reviewer 1: It is said that periodontal screening should be carried out on pregnant women to find out their periodontal situation, and from there to apply statistics, records and treatment; but it is not explained how this is to be carried out.No action plan is specified.It is only recommended to implement actions to prioritise oral health and to establish joint boundaries between specialties.Therefore, it will be good to start from this document a prospective cohort study design, in order to present guidelines to the Ministry of Health.
Response: Thank you.We would like to avoid being too specific by saying that a prospective cohort study design should be conducted in our recommendations, because all research investigations should be welcome by the government on this area.However, this we will put at the back of our mind.We will be very glad to pursue a research project on that and we are very open to collaborative opportunities.

1 Reviewer
relationship to systemic diseases, pregnancy and oral health I confirm that I have this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.VersionReport 22 July 2024 https://doi.org/10.5256/f1000research.167558.r298808© 2024 Velosa-Porras J.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Juliana Velosa-Porras Pontificia Universidad Javeriana, Bogotá, Colombia Dear Authors, It was a pleasure for me to read your manuscript.The research topic is of interest, countries with limited resources should incorporate these strategies to promote oral health and prevent diseases such as preterm birth.As the first point of contact with patients, this manuscript shows the fundamental role of nurses and midwives in the prevention of oral diseases.Minor revision I suggest this two references: Pockpa ZAD, et.al., 2022 (Ref 1) ○ Muwazi L, et.al., 2014 (Ref 2) ○ Background I suggest that sentences 1 and 6 in the first paragraph could be synthesized -the information is the same.

Does the paper provide a comprehensive overview of the policy and the context of its implementation in a way which is accessible to a general reader? Yes Is the discussion on the implications clearly and accurately presented and does it cite the current literature? No Are the recommendations made clear, balanced, and justified on the basis of the presented arguments
paragraph, line 2 -" ….. the lead author of this policy brief, in October 2024 where there….." Please check the wording.Please check this date, since it has not yet passed, I believe it was a typing error.
? YesCompeting Interests: No competing interests were disclosed.Reviewer Expertise: Clinical Epidemiology, Epidemiology, Periodontics, Periodontal disease and its relationship to systemic diseases, pregnancy and oral health I

confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
○ Muwazi L, et.al., 2014 (Ref 2) ○

Reviewer 2-Actionable recommendations:
First paragraph, line 2 -" ….. the lead author of this policy brief, in October 2024 where there….." Please check the wording.Please check this date, since it has not yet passed, I believe it was a typing error.Response: Thank you.This sentence has now been revised.Thank you.We have now cited these two references in the revised manuscript.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalonia, Spain 2 Sant Joan de Déu Hospital, Institut de Recerca Sant Joan de Déu (IRSJD), University of Barcelona, I enjoyed reading this manuscript.Especially in countries where there is a shortage of dental surgeons it is important to involve nurses in oral health education.Maternity is important in women's lives so midwives need to acquire knowledge about periodontitis and its possible repercussions on the foeto-placental unit.Perhaps I could suggest to the authors to add these three references as they are studies also carried out in East Africa.