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You are here: HomeRecommendations for Primary Care PracticePublished RecommendationsRecommendation SummaryOther Supporting Document : Reducing Risk for Mother-to-Infant Transmission of Hepatitis C Virus: A Systematic Review for the U.S. Preventive Services Task Force

Reducing Risk for Mother-to-Infant Transmission of Hepatitis C Virus: A Systematic Review for the U.S. Preventive Services Task Force

Other Supporting Document for Hepatitis C: Screening

Preface

Release Date: November 2012


By Erika Barth Cottrell, PhD, MPP; Roger Chou, MD; Ngoc Wasson, MPH; Basmah Rahman, MPH; and Jeanne-Marie Guise, MD, MPH


The information in this article is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This article is intended as a reference and not as a substitute for clinical judgment.

This article may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

This article was first published in Annals of Internal Medicine on November 27, 2012 (Ann Intern Med 2012; http://www.annals.org).

Abstract

Background: Mother-to-infant transmission is the leading cause of childhood hepatitis C virus (HCV) infection, with up to 4000 new cases each year in the United States.

Purpose: To evaluate effects of mode of delivery, labor management strategies, and breastfeeding practices on risk for mother-to-infant transmission of HCV.

Data Sources: MEDLINE (1947 to May 2012), the Cochrane Library Database, clinical trial registries, and reference lists.

Study Selection: Randomized trials and observational studies on mode of delivery, labor management strategies, and breastfeeding practices and risk for mother-to-infant transmission of HCV.

Data Extraction: Investigators abstracted and reviewed study details and quality using predefined criteria.

Data Synthesis: Eighteen observational studies evaluated the association between mode of delivery, labor management strategies, or breastfeeding practices and risk for mother-to-infant HCV transmission. Fourteen studies (2 good-quality, 4 fair-quality, and 8 poor-quality studies) found no clear association between mode of delivery (vaginal versus cesarean delivery) and risk for transmission. Two studies (1 good-quality, 1 poor-quality study) reported an association between prolonged duration of ruptured membranes and increased risk for transmission. Fourteen studies (2 good-quality, 2 fair-quality, and 10 poor-quality studies) found no association between breastfeeding and risk for transmission.

Limitations: Only English-language articles were included. Studies were observational, and most had important methodologic shortcomings, including failure to adjust for potential confounders and small sample sizes.

Conclusion: No intervention has been clearly demonstrated to reduce the risk for mother-to-infant HCV transmission. Avoidance of breastfeeding does not appear indicated for reducing transmission risk.

Primary Funding Source: Agency for Healthcare Research and Quality.

Introduction

An estimated 40,000 children are born to hepatitis C virus (HCV)–positive women each year1. Mother-to-infant (vertical) transmission is the main route of childhood HCV infection2. Estimates for the rate of vertical transmission range from 3% to 10%2-5. Risk for transmission is highest among women with a high viral load at delivery2-6 and those co-infected with HIV5, 7. Although antiviral therapies are contraindicated in pregnancy because of teratogenic risks, prenatal HCV screening to identify HCV-infected women unaware of their status might lead to other interventions during labor and delivery or in the perinatal period that reduce risk for mother-to-infant transmission8.

The purpose of this review was to synthesize the evidence on the effects of mode of delivery, labor management strategies, and breastfeeding practices on risk for mother-to-infant transmission. This review was performed as part of a larger report on HCV screening9 and will be used by the U.S. Preventive Services Task Force (USPSTF) to inform its prenatal HCV screening recommendations.

Methods

Scope

We developed a review protocol by using a standardized process with input from experts and the public to address the following key question: “What is the effect of mode of delivery, labor management strategy, or breastfeeding on risk for mother-to-infant transmission of HCV?” Detailed methods and data for the review, including the full USPSTF analytic framework on screening, search strategies, detailed abstraction tables, and quality ratings of individual studies, are available in the full report9.

Data Sources

A research librarian searched Ovid MEDLINE (1947 to May 2012), EMBASE, the Cochrane Library Database, Scopus, PsycINFO, clinical trial registries (including clinicaltrials.gov), and grants databases. We supplemented electronic searches by reviewing reference lists of retrieved articles. Searches were peer reviewed by a second librarian.

Study Selection

At least 2 reviewers independently evaluated each study to determine inclusion eligibility. We selected for full review randomized trials, cohort studies, and case–control studies that evaluated the association between mode of delivery (cesarean versus vaginal delivery), labor management strategies (use of internal fetal monitoring or management of premature rupture of membranes), or breastfeeding on risk for mother-to-infant transmission. We restricted inclusion to English-language articles and excluded studies published only as abstracts. Women co-infected with HIV are advised to avoid breastfeeding and deliver by elective cesarean if they are viremic in order to reduce risk for HIV transmission10. Therefore, we excluded studies of HIV co-infected women, unless results for women not co-infected with HIV were reported separately or co-infected women made up less than 10% of the study sample.

Data Extraction and Quality Rating

One investigator abstracted details about the study design, patient population, setting, interventions, analysis, follow-up, and results. A second investigator reviewed data for accuracy. Two investigators independently applied predefined criteria to assess the quality of each study as good, fair, or poor11-13. Discrepancies were resolved through a consensus process.

Data Synthesis

We assessed the overall strength of each body of evidence as “high,” “moderate,” “low,” or “insufficient” in accordance with the AHRQ “Methods Guide for Comparative Effectiveness Reviews”14, based on the quality of studies, consistency between studies, precision of estimates, and directness of evidence.

Role of the Funding Source

This research was funded by AHRQ's Effective Health Care Program. Investigators worked with AHRQ staff to develop and refine the scope, analytic framework, and key questions. AHRQ staff had no role in study selection, quality assessment, synthesis, or development of conclusions. AHRQ staff provided project oversight, distributed the draft report for peer review, and reviewed the draft report and manuscript. The investigators are solely responsible for the content of the manuscript and the decision to submit for publication.

 

Results

The search and selection of articles are summarized in the study flow diagram (Appendix Figure). Of 2580 potentially relevant citations, 444 articles were selected for full-text review and 18 met inclusion criteria.

Mode of Delivery

Fourteen observational studies reported in 16 publications (sample sizes of 56 to 1034 mother–infant pairs) evaluated the association between mode of delivery and vertical transmission of HCV (Appendix Table)4, 5, 15-28. Nine studies were conducted in Europe4, 15-17, 19-21, 23, 25, 27, 28, 2 in Australia18, 24, 2 in Japan22, 26, and 1 in the United States5. Two studies were rated as good quality5, 15, 16, 4 fair quality4, 19, 21, 23, and the remainder poor quality. Two reports from the European Pediatric Hepatitis C Network evaluated overlapping populations15, 16, and 2 studies evaluated nonoverlapping (different time periods of enrollment) populations in Dublin, Ireland19, 21. Only 4 studies adjusted for potential confounders in analyses4, 5, 15, 16, 19; no study reported baseline characteristics according to mode of delivery or matched women on key potential confounders.

Four studies5, 15, 19, 21 totaling 2080 mother–infant pairs (2 good-quality5, 15 and 2 fair-quality19, 21 studies) compared risk for transmission after elective cesarean delivery before the onset of labor versus vaginal or emergency (after onset of labor) cesarean delivery (Appendix Figure). Three of these studies5, 19, 21 reported higher transmission risk after vaginal or emergent cesarean delivery, but the difference was statistically significant in only 1 fair-quality study19. That study (n = 424) reported no cases of transmission after elective cesarean delivery, compared with 7.4% after vaginal or emergency cesarean delivery (adjusted odds ratio, 0.0 [95% CI, 0.0 to 0.87])19. The 2 good-quality studies reported conflicting results. One (n = 181) reported a direction of effect that was not statistically significant but was similar to that of the fair-quality study, with a vertical transmission rate of 4.1% (7 of 169) after vaginal or emergent cesarean delivery compared with no cases after 12 elective cesarean births (relative risk, 1.1 [CI, 0.07 to 19])5. The other, larger (n = 1034) good-quality study found elective cesarean to be associated with increased risk for vertical transmission compared with vaginal or emergency cesarean delivery (adjusted odds ratio, 1.6 [CI, 0.88 to 2.9])15.

Eleven studies (total of 2308 mother–infant pairs) compared the risk for vertical transmission after vaginal versus cesarean delivery, without specifying whether the cesarean delivery was elective or emergent (Appendix Figure)4, 16-18, 20, 22-28. Ten of the 11 studies (1 good-quality16, 2 fair-quality4, 23, and 8 poor-quality17, 18, 20, 22, 24-28 studies) found no association between mode of delivery and risk for HCV transmission4, 16-18, 20, 23-28. The exception was 1 small (n = 59), poor-quality Japanese prospective cohort study that reported a statistically significant increase in risk with vaginal delivery in a subgroup of women with high viral load (≥2.5 x 106 RNA copies/mL)22.

Labor Management

Internal Fetal Monitoring

Three studies (2 good-quality5, 16 studies and 1 fair-quality21 study) reported conflicting findings on the relationship between use of internal fetal monitoring and risk for vertical transmission (Appendix Figure). One good-quality study (n = 181)5 found internal fetal monitoring versus no monitoring was associated with increased risk (adjusted odds ratio, 6.7 [CI, 1.1 to 36]), but another, larger good-quality study (n = 724) found no association (relative risk, 1.2 [CI, 0.70 to 2.2])16.

Duration of Rupture of Membranes

One good-quality study5 and 1 poor-quality study24 (total of 245 mother–infant pairs) found an association between longer duration of rupture of membranes and increased risk for transmission (Appendix Figure). The good-quality study reported greater risk for vertical transmission in women with membrane rupture longer than 6 hours (odds ratio, 9.3 [CI, 1.5 to 180]) 5. The poor-quality study reported longer average duration of membrane rupture in women who transmitted virus to their infant than in those who did not transmit virus (28 versus 16 hours; P = 0.03)24.

Breastfeeding

Fourteen cohort studies (total of 2971 mother–infant pairs) found no association between breastfeeding by women infected with HCV and risk for transmission to infants (Appendix Figure)5, 15, 17, 19, 20, 23-32. Most studies prospectively followed infants for at least 1 year. Sample sizes ranged from fewer than 5029, 31, 32 to more than 100015. Two studies were rated good quality5, 15, 2 fair quality19, 23, and 10 poor quality17, 20, 24-32. Methodologic shortcomings in the poor-quality studies included failure to perform statistical adjustment on potential confounders and insufficient information to determine comparability of groups at baseline stratified by breastfeeding status.

Discussion

Vertical transmission is the leading cause of childhood HCV infection, and identification of effective management strategies to reduce risk for transmission is an important clinical and public health concern. However, the primary finding of this review as summarized in the Table is that no perinatal management strategy has clearly been shown to reduce risk for HCV transmission. Observational studies consistently found no evidence of an association between breastfeeding and risk for vertical transmission, consistent with data suggesting that transmission typically occurs in utero23, 33. Evidence on the effects of labor management strategies and mode of delivery on risk for transmission was somewhat conflicting. Two studies5, 24 reported increased risk for HCV transmission with more prolonged duration of ruptured membranes, similar to findings for other infectious agents transmitted vertically (such as group B streptococcus and HIV). However, other studies did not find vaginal delivery associated with increased risk for vertical transmission versus cesarean delivery, and the largest single study15 reported a non–statistically significant trend toward decreased risk, even though vaginal delivery is associated with longer duration of ruptured membranes. Possible explanations for the failure to find an association between vaginal delivery and increased risk for transmission could include threshold or modifying effects related to the duration of rupture, viral load, or other factors. Cohort studies that focus on women with longer rupture of membranes or high viral load and perform statistical adjustment on other potential confounding factors could help clarify the effects of mode of delivery on transmission risk. Randomized trials are less susceptible to confounding but would involve potential challenges related to the acceptability of randomly assigning HCV-infected women to elective cesarean delivery versus planned vaginal birth.

Other reviews and reports were consistent with our findings. A review of cesarean delivery versus vaginal delivery for preventing mother-to-infant HCV transmission found no randomized trials and concluded that a systematic review of observational studies is needed34. A 2007 American College of Obstetricians and Gynecologists report identified a possible association between prolonged rupture of membranes after labor and increased risk for vertical transmission but concluded that no preventive measures have been proven effective for reducing the risk for mother-to-infant transmission35.

Our review has limitations. Evidence on the effects of interventions to prevent mother-to-infant transmission was restricted to observational studies, most with methodologic shortcomings (including failure to adjust for confounders) and small sample sizes. If practices that are more effective at reducing transmission are preferentially used in women at higher risk, this could have biased results toward null findings. We excluded non–English-language articles, which could result in language bias. We were also unable to formally assess publication bias due to small numbers of studies and methodologic shortcomings in the studies.

This review was conducted as part of a larger review on HCV screening9. For prenatal screening to be effective, there must be an effective intervention. Our findings indicate that avoidance of breastfeeding is not warranted to reduce risk for vertical transmission. Given limited evidence of an association between prolonged rupture of membranes and increased transmission risk, clinicians may consider avoiding prolonged rupture of membranes in HCV-infected women until more definitive data are available.

Copyright and Source Information

Source: Agency for Healthcare Research and Quality.

Acknowledgment: The authors thank Robin Paynter, MLIS; Rose Campbell, MLIS; Christina Bougatsos, MPH; Ian Blazina, MPH; Tracy Dana, MLS; Jessica Griffin, MS; AHRQ Task Order Officer Christine Chang, MD, MPH; and USPSTF Medical Officer Iris Mabry-Hernandez, MD, MPH.

Grant Support: From the Agency for Healthcare Research and Quality (Contract Number 290-2007-10057-I, Task Order 8), Rockville, Maryland.

Potential Conflicts of Interest: Dr. Cottrell: Other: unpaid board member of AHRQ. Dr. Chou: Grant: AHRQ. Dr. Wasson: Grant: AHRQ. Dr. Guise: Grant (money to institution):AHRQ (5. HHSA 290-2007-10057, task order no. 6); Support for travel to meetings for the study and other purposes: AHRQ; Provision of writing assistance, medicines, equipment, or administrative support (money to institution): AHRQ. Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-1085.

Requests for Single Reprints: Roger Chou, MD, 3181 SW Sam Jackson Park Road, Mail Code BICC, Portland, OR 97239; e-mail, chour@ohsu.edu.

Current author addresses and author contributions are available at http://www.annals.org.

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Table. Summary of Evidence: Effect of Mode of Delivery, Labor Management Strategies, or Breastfeeding Practices on Risk for Mother-to-Child Transmission of HCV*

Overall Strength of Evidence Studies Identified, n
Participants, n
Overall
Quality
Consistency
(High,
Moderate,
Low)
Directness
(Direct or
Indirect)
Precision
(High,
Moderate,
Low)
Summary of Findings
Mode of delivery
Elective cesarean versus vaginal delivery/emergent cesarean
Low 4 cohort studies
2080
Fair Moderate Direct Low The 2 good-quality studies found no statistically significant difference in risk for transmission with elective cesarean versus vaginal delivery, with trends in opposite directions
Any cesarean (elective or emergent) versus vaginal delivery
Moderate 11 cohort studies
2308
Fair High Direct Low Ten of 11 studies (1 good-quality) found no statistically significant difference in risk for transmission with cesarean (not specified whether elective or emergent) versus vaginal delivery
Labor management
Internal fetal monitoring versus no internal fetal monitoring
Insufficient 3 cohort studies
928
Fair Moderate Direct Low Three studies (2 good-quality) found inconsistent evidence on the risk for transmission with fetal monitoring, with no association in 2 studies and increased risk for transmission in 1 of the good-quality studies (adjusted OR, 6.7 [95% CI, 1.1–36])
Prolonged rupture of membranes versus less prolonged rupture of membranes
Low 2 cohort studies
245
Fair High Direct Low Two studies (1 good-quality, 1 poor-quality) found an association between longer duration of rupture of membranes and risk for transmission, with the good-quality study reporting higher risk for transmission with membrane rupture >6 hours (adjusted OR, 9.3 [CI, 1.5–180])
Breastfeeding
Breastfeeding versus no breastfeeding
Moderate 14 cohort studies
2971
Fair High Direct High Fourteen studies found no significant association between breastfeeding and risk for transmission

HCV = hepatitis C virus; OR = odds ratio.
* The full report is available on the Agency for Healthcare Research and Quality Web site at www.effectivehealthcare.ahrq.gov9.

Appendix Table. Studies on Mode of Delivery, Labor Management Strategies, and Breastfeeding Practices and Mother-to-Infant Transmission of HCV

Study, Year, Country
(Reference)
Quality
Participants, n Age (y)
Nonwhite
Participants, %
HIV-Positive
Participants, %
HCV Viral Load, RNA
copies x 106/L
Results* (95% CI)
Mode of delivery
Elective cesarean versus vaginal delivery/emergent cesarean
EPHN (Tovo), 2005, Italy, Spain, Germany, Ireland, Scotland, Belgium, Sweden15
Good
1034 Mean (SD), 31.7 (5.17)
NR
0
NR
Rates not reported
OR, 1.57 (0.88–2.83); P = 0.13; unadjusted OR, 1.59 (0.88–2.86); P = 0.13; adjusted for sex, mode of delivery, prematurity, and breastfeeding
Gibb et al, 2000, Ireland, United Kingdom19
Fair
424 Mean (SD), 27 (6)
6
5
NR
0/31 (0%) versus 29/393 (7.4%)
OR, 0 (0–0.87); P = 0.04; adjusted for HIV status and breastfeeding
Mast et al, 2005, USA5
Good
181 <20 y: 7 (2.9%)
20–29 y: 103 (42.9%)
30–39 y: 120 (49.6%)
≥40 y: 12 (4.9%)
67.4
0
Mean HCV RNA level at delivery: 2.38
0/12 (0%) versus 7/169 (4.1%)
RR, 1.1 (0.07–19)
McMenamin et al, 2008, Ireland21
Fair
441 Median (range), 26 (16–44)
NR
5.9
NR
1/33 (3%) versus 17/408 (4.2%)
RR, 0.73 (0.09–5.30)
Total 2080      
Any cesarean (elective or emergent) versus vaginal delivery
EPHN (Pembrey), 2001, Italy, Spain, Germany, Ireland, Scotland, Belgium, Sweden16
Good
884 <20 y: 219 (17%)
20–25 y: 563 (43%)
30–39 y: 495 (38%)
≥40 y: 34 (3%)
NR
0
NR
15/218 (6.9%) versus 39/666 (5.9%)
OR, 1.17 (0.59–2.31); adjusted for breastfeeding, maternal age at delivery, center category
Ceci et al, 2001, Italy4
Fair
78 Median (range), 30 (21–42)
N
0
<0.2: 9 (15%)
>0.2: 51 (85%)
No association (data not reported)
Conte et al, 2000, Italy17
Poor
365 Mean (SD), 30.9 (5.2)
NR
4%
NR
1/106 (0.9%) versus 7/259 (2.7%)
RR, 0.35 (0.04–2.80)
Garland et al, 1998, Australia18
Poor
83 NR
NR
0
NR
0/22 (0%) versus 3/61 (4.9%)
RR not calculated
La Torre et al, 1998, Italy20
Poor
80 NR
NR
0
NR
1/14 (7.1%) versus 1/66 (1.5%)
RR, 4.71 (0.31–70.94)
Okamoto et al, 1999, Japan22
Poor
59 NR
NR
0
≥2.5: 21 (25%)
0/18 (0%) versus 7/41 (14%)
RR not calculated (P = 0.045)
0/10 (0%) versus 7/16 (44%) in women with high viral load (P = 0.023)
Resti et al, 1998, Italy23
Fair
275 NR
NR
0
NR
4/62 (6.5%) versus 9/213 (4.2%)
RR, 1.53 (0.48–4.79)
Spencer et al, 1997, Australia24
Poor
63 Mean: 30
NR
0
NR
1/7 (14%) versus 5/55 (9.1%)
RR, 1.57 (0.21–11.6)
Syriopoulou et al, 2005, Greece25
Poor
56 Mean (SD), 29.6 (3)
NR
2
NR
0/17 (0%) versus 2/39 (5.1%)
RR not calculated (P = 0.34)
Tajiri et al, 2001, Japan26
Poor
114 NR
NR
0
High: 46 (40%)
Low: 27 (24%)
NR: 41 (36%)
1/24 (4.2%) versus 8/90 (8.8%)
RR, 0.46 (0.61–3.53)
Zanetti et al, 1998,28 and 199927, Italy
Poor
251 NR
NR
0
NR
1/58 (1.7%) versus 7/193 (3.6%)
RR, 0.48 (0.06–3.79)
Total 2308      
Labor management
Internal fetal monitoring versus no internal fetal monitoring
EPHN (Pembrey), 2001, Italy, Spain, Germany, Ireland, Scotland, Belgium, Sweden16
Good
724 <20 y: 219 (17%)
20–25 y: 563 (43%)
30–39 y: 495 (38%)
≥40 y: 34 (3%)
NR
0
NR
11/93 (11.8%) versus 58/631 (9.2%)
RR, 1.24 (0.70–2.2)
Mast et al, 2005, USA5
Good
181 <20 y: 7 (2.9%)
20–29 y: 103 (42.9%)
30–39 y: 120 (49.6%)
≥40 y: 12 (4.9%)
67.4
0
Mean HCV RNA level at delivery: 2.38
3/16 (18.8%) versus 4/165 (2.4%)
RR, 7.7 (1.9–31.6); P = 0.02; unadjusted
OR, 6.7 (1.1–35.9); adjusted for maternal demographic characteristics, HCV RNA level, history of intravenous drug use, and cigarette smoking during pregnancy
McMenamin et al, 2008, Ireland21
Fair
23 Median (range), 26 (16–44)
NR
5.9
NR
Infant HCV RNA-positive: 0/11 (0%)
Infant not tested for HCV: 12
RR undefined
Total 928      
Prolonged rupture of membranes versus less prolonged rupture of membranes
Mast et al, 2005, USA5
Good
182 <20 y: 7 (2.9%)
20–29 y: 103 (42.9%)
30–39 y: 120 (49.6%)
≥40 y: 12 (4.9%)
67.4
0
Mean HCV RNA level at delivery: 2.38
<1 versus 1–5 versus 6–12 versus =13 h:
0/53 versus 1/59 (1.7%) versus 4/40 (10%) versus 2/30 (6.7%); P = 0.02
Membrane rupture >6 h
OR, 9.3 (1.5–179.7); adjusted for maternal demographic characteristics, HCV RNA level, fetal monitoring, history of intravenous drug use, and cigarette smoking during pregnancy
Spencer et al, 1997, Australia24 63 Mean: 30
NR
0
NR
Mean duration (SD), transmitted versus not transmitted: 28 (10) h versus 16 (4) h (P = 0.03)
Total 245      
Breastfeeding
Breastfeeding versus no breastfeeding
Conte et al, 2000, Italy17
Poor
370 Mean (SD), 30.9 (5.2)
NR
4
NR
2/90 (2.2%) versus 6/280 (2.1%)
RR, 1.02 (0.30–3.45)
Gibb et al, 2000, Ireland, United Kingdom19
Fair
414 Mean (SD), 27 (6)
6
5
NR
7.7% versus 6.7%
OR, 1.52 (0.35–5.12); adjusted for HIV status and mode of delivery
La Torre et al, 1998, Italy20
Poor
80 NR
NR
0
NR
0/10 (0%) versus 2/46 (4.3%)
RR not calculated
Lin et al, 1995, China29
Poor
15 NR
NR
0
NR
0/11 (0%) versus 0/4 (0%)
RR not calculated
Mast et al, 2005, USA5
Good
182 <20 y: 7 (2.9%)
20–29 y: 103 (42.9%)
30–39 y: 120 (49.6%)
≥40 y: 12 (4.9%)
67.4
0
Mean HCV RNA level at delivery: 2.38
2/62 (3.2%) versus 5/120 (4.2%)
RR, 0.8 (0.2–3.9)
Moriya et al, 1995, Japan30
Poor
74 NR
NR
0
NR
5/6 infected (83%) versus 54/68 uninfected (79%) were breastfed (case–control design)
OR, 1.3 (0.14–12.0)
Pipan et al, 1996, Italy31
Poor
25 Mean (range), 26.4 (19–35)
NR
0
NR
0/6 (0%) versus 0/19 (0%)
RR not calculated
Resti et al, 1998, Italy23
Fair
275 NR
NR
0
NR
6/87 (6.9%) versus 7/188 (3.7%)
RR, 1.85 (0.64–5.35)
Spencer et al, 1997, Australia24 63 Mean: 30
NR
0
NR
2/33 (6.0%) versus 4/13 (13%)
RR, 0.45 (0.09–2.31)
Syriopoulou et al, 2005, Greece25
Poor
56 Mean (SD), 29.6 (3)
NR
2
NR
0/15 (0%) versus 2/41 (4.9%)
RR not calculated (P = 0.38)
Tajiri et al, 2001, Japan26
Poor
114 NR
NR
0
High: 46 (40%)
Low: 27 (24%)
NR: 41 (36%)
9/98 (9.2%) versus 0/16 (0%)
RR not calculated (P = 0.243)
Tanzi et al, 1997, Italy32
Poor
18 NR
NR
0.27%
NR
0% (0/12) versus 0% (0/6)
12/18 HCV RNA–positive mothers breastfed, none infected at 3-mo follow-up
EPHN (Tovo), 2005, Italy, Spain, Germany, Ireland, Scotland, Belgium, Sweden15
Good
1034 Mean (SD), 31.7 (5.17)
NR
0
NR
Rates not reported
OR, 0.88 (0.48–1.61); unadjusted
OR, 0.92 (0.50–1.70); adjusted for sex, prematurity, and mode of delivery
Zanetti et al, 1998, 28 and 199927, Italy
Poor
251 NR
NR
0
NR
3/127 (2.4%) versus 5/124 (4.0%)
RR, 0.59 (0.14–2.40)
Total 2971      

EPHN = European Paediatric Hepatitis C Virus Network; HCV = hepatitis C virus; NR = not reported; OR = odds ratio; RR = relative risk; SD = standard deviation.
* Unadjusted unless otherwise indicated.

Appendix Figure. Summary of evidence search and selection.

Select Text Description below for details

† One study resulting in 2 publications.
* Includes hand searches and gray literature searches.

Text Description.

The study flow diagram summarizes the search and selection of articles addressing the effect of mode of delivery, labor management strategies, or breastfeeding practices on risk for mother-to-infant transmission of hepatitis C virus. Reproduced from reference.9

Current as of: November 2012

Internet Citation: Reducing Risk for Mother-to-Infant Transmission of Hepatitis C Virus: A Systematic Review for the U.S. Preventive Services Task Force: Hepatitis C: Screening. U.S. Preventive Services Task Force. November 2012.
https://www.uspreventiveservicestaskforce.org/Page/Document/reducing-risk-for-mother-to-infant-transmission-of-hepatitis-c-virus-a-systematic-review-for-the-us-preventive-services-task-force/hepatitis-c-screening

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