The Role of Caesarean Section and Nonbreastfeeding in Preventing Mother-to-child Transmission of Hepatitis B Virus in HBsAg-and HBeAg-positive Mothers

Results From a Prospective Cohort Study and a Meta-analysis

Yu-Chen Pan; Zhi-Fang Jia; Yue-Qi Wang; Na Yang; Jian-Xun Liu; Xiang-Jun Zhai; Ying Song; Chong Wang; Jie Li; Jing Jiang


J Viral Hepat. 2020;27(10):1032-1043. 

In This Article

Abstract and Introduction


The study aimed to assess whether caesarean section and nonbreastfeeding can prevent mother-to-child transmission (MTCT) in HBsAg- and HBeAg-positive mothers via a cohort study and a meta-analysis. (1) Pregnant women who were positive for HBsAg and HBeAg and did not receive antiviral treatment during pregnancy were recruited from the First Hospital of Jilin University, Maternal and Child Health Care Center of Jiangsu and Henan from August 2009 to June 2015. Infants received active and passive immunity. (2) In addition, a systematic literature search was performed in the PubMed, Embase, Cochrane, China National Knowledge Infrastructure and Wanfang Chinese databases. The retrieval strategy was [("HBV" or "hepatitis b" or "hepatitis b virus") and ("mother-to-infant transmission" or "vertical transmission")]. Studies were screened, and data were extracted. The fixed-effect model was used to analyse the studies. A total of 852 mothers and 857 newborns were enrolled. At the age of 7 months, 41 infants (4.78%) were positive for HBsAg. Multivariate analysis showed that mothers with higher HBV DNA levels (>108 IU/mL; RR = 3.03, 95% CI: 1.41–6.52) were associated with an increased risk of infection. Although there was no statistical significance, caesarean section (RR = 0.61) and nonbreastfeeding (RR = 0.88) showed a tendency to reduce the risk of infection. (2) A total of 5726 studies were identified. Together with our study, 13 were included in the analysis of delivery mode, and 12 were included in the analysis of feeding mode. The risk of infection in the caesarean section group was lower than that in the vaginal delivery group (RR = 0.58, 95% CI: 0.46–0.74). In the analysis of feeding mode, the risk in the nonbreastfeeding group was significantly lower (RR = 0.74, 95% CI: 0.56–0.98). In conclusion, caesarean section and nonbreastfeeding reduced the risk of MTCT in infants of HBsAg- and HBeAg-positive mothers who did not receive antiviral therapy during pregnancy.


Hepatitis B virus (HBV) infection is one of the major public health burdens worldwide. According to data from the World Health Organization (WHO), nearly 257 million people were living with chronic HBV infection in 2015, and HBV results in 887 000 deaths every year worldwide, including death from liver failure, cirrhosis and liver cancer.[1,2] China is one of the highest prevalence areas of HBV worldwide.[3] It is estimated that 93 million people are infected with HBV in China, including 20 million with chronic hepatitis B.[4]

When HBV infection occurs during the perinatal period through mother-to-child transmission (MTCT), the rate of chronic infection is as high as 90%; in the infant period, the rate is 25%-30%;[5,6] and after 5 years of age, the rate decreases to 5%-10%. Moreover, infection in infants is more likely to progress to cirrhosis and hepatocellular carcinoma.[7] Therefore, the prevention of MTCT of HBV will be meaningful to eventually eliminate the burden of HBV infection.[8]

The MTCT rate of HBV has decreased significantly due to both passive and active immunization using hepatitis B immune globulin (HBIG) and HBV vaccine in the neonatal period. However, transmission still occurs in 11.0% of infected mothers who were positive for hepatitis B e antigen (HBeAg).[9] Recently, oral antiviral drugs (telbivudine, tenofovir or lamivudine) have been clinically recommended to block MTCT at 28–32 weeks for pregnant women with a high viral load and normal liver function. However, the long-term safety of antiviral drugs is still under investigation. On the other hand, not all pregnant women would take the drug during pregnancy. Therefore, it is still crucial to explore the factors associated with MTCT among mothers not taking antiviral drugs.

In recent years, scholars have been concerned about the effects of delivery mode and feeding mode on MTCT. The benefits of breastfeeding for newborns are well known. WHO suggests that chronic HBV infection of the mother should not be a reason to avoid breastfeeding.[10] However, some researchers have suggested the possibility of HBV transmission through breastfeeding since Linnemann reported the presence of HBsAg in the breast milk of chronically infected mothers and other researchers have found HBeAg and HBV DNA in breast milk.[11,12] Caesarean section (CS) is considered a method of reducing the risk of MTCT for some viruses, such as human immunodeficiency virus and herpes simplex virus.[13,14] However, the effect of delivery mode on MTCT of HBV remains controversial.[15,16] Previous studies have considered that nonbreastfeeding and caesarean section had no association with MTCT of HBV, but many studies have shown a tendency towards decreased risk in statistics. Accordingly, we explored the role of CS and nonbreastfeeding in MTCT in high-risk groups: mothers who both were positive for HBsAg and HBeAg and did not receive antiviral therapy during pregnancy. Considering that the number of infections in a single study was insufficient, we searched the literature extensively, synthesized related studies and conducted a meta-analysis to discuss it in depth.