Is parity a cause of tooth loss? Perceptions of northern Nigerian Hausa women

Background Reproduction affects the general health of women, especially when parity is high. The relationship between parity and oral health is not as clear, although it is a widespread customary belief that pregnancy results in tooth loss. Parity has been associated with tooth loss in some populations, but not in others. It is important to understand the perceptions of women regarding the association between parity and tooth loss as these beliefs may influence health behaviors during the reproductive years. Aim To explore the views of Hausa women regarding the link between parity and tooth loss. Methods Qualitative data were collected through a grounded theory approach with focus group discussions (FGDs) of high and low parity Hausa women (n = 33) in northern Nigeria. Responses were elicited on the causes of tooth loss, effects of tooth loss on women’s quality of life, issues of parity and tooth loss, and cultural beliefs about parity and tooth loss. The data were analyzed thematically using ATLAS-ti. Results Respondents associated tooth loss with vomiting during labor, a condition termed ‘payar baka’. Poor oral hygiene, excessive consumption of refined carbohydrates, tooth worm, cancer and ageing were also believed to cause tooth loss. The greatest impacts of tooth loss on the lives of the respondents were esthetic and masticatory changes. Conclusion Respondents perceived that parity is indirectly linked to tooth loss, as reflected in their views on the association between vomiting during labor and tooth loss. A grounded theory approach, involving in-depth focus group discussions (FGDs) of high and low parity Hausa women in northern Nigeria, was implemented. This approach is suitable for obtaining data on married women’s views regarding parity and tooth loss. A repetitive method of data collection and analysis was employed to develop a theoretical explanation of perceptions grounded in the data collected from the discussions with Hausa women. The sample population was selected through a household survey in the Kumbotso Local Government Area (LGA) of Kano State, Nigeria using a multi-stage random sampling technique. Kano State is located in the northwest zone of Nigeria and has a population of 9.4 million [40]. Kumbotso LGA has its headquarters in the town of Kumbotso. The population is 295,979 people who live in an area of 158 km2. The LGA consists of 11 administrative wards. According to the 2006 census, 66,010 women aged 15–65 years reside in Kumbotso LGA. Six wards were randomly selected from the LGA. Within each ward, two communities were randomly selected and all households in each community were approached. A purposive selection [41] of women from different age cohorts and parity levels was identified from the participants in a general study on maternal and child oral health in Kano. The sample consisted of 33 women aged 19–66 years with the size determination based on the theoretical saturation concept of Grounded Theory [42]. Women of all parity levels were included. Participants were grouped into three age cohorts (19–30 years, 31–45 years and 46–66 years) and each group consisted of an average of five women. Trained bilingual Hausa and English-speaking married women with previous experience in qualitative interviewing, along with the principal investigator, conducted the FGDs. The use of local Muslim Hausa women as field workers helped facilitate access to women in seclusion, promoted openness among the women during the FGDs, and minimized the potential objections and suspicions of participant’s husbands. The local field workers were not assigned to groups in their own areas. Two FGD sessions were conducted per age cohort, for a total of six gatherings. Sessions were conducted in a quiet meeting room, and the discussions were moderated with the use of an interview guide that was prepared before the sessions. The FGDs obtained responses to queries on the following topics: causes of tooth loss, effects of tooth loss on the quality of women’s lives, issues regarding parity and tooth loss, and cultural beliefs on parity and tooth loss. All interviews were taped, transcribed, and translated verbatim from Hausa into English. Two Hausa language teachers at Bayero University, Kano, and two Hausa-speaking dentists (also from Kano State and not involved in the study) supervised the transcription and translation. Ethical clearance for the study was obtained from the Ethics and Research Committee of Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria (IPHOAU/12/717) and from the Human Research Ethics Committee of the University of the Witwatersrand, Johannesburg (M170343). A male local assistant who could speak Hausa fluently was employed to facilitate links with village leaders and husbands. Permission was obtained from local village leaders to conduct the study and informed consent was obtained from the husbands of married women living with their husbands. Written informed consent was obtained from each participant. The consent form was translated into Hausa and read to the participants who were not literate. Women who were not literate and were willing to participate in the study thumb printed on the consent form. Using the grounded theory approach, open, focused and axial coding was employed [42–47]. Throughout the analysis, memoing was done to facilitate the hypothesis formulation [48]. Two major theoretical categories were generated around the assumptions and beliefs attached to childbearing and tooth loss in women: the causes of tooth loss and the effects of tooth loss on women of childbearing age. Network diagrams were drawn using the network view function of ATLAS.ti to show the relationships between categories and to display the models to explore the data and visualize the ideas and findings [49]. Illustrative direct quotations were drawn from the text to highlight key findings.