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Elective cesarean section and bottle-feeding do not reduce infection of hepatitis B in infants of high viremic mothers: a retrospective study

BMC Pregnancy and Childbirth volume 25, Article number: 482 (2025) Cite this article

Abstract

Background

Studies on the issue of whether elective cesarean section (ECS) may reduce mother-to-child transmission (MTCT) of HBV in infants of carrier mothers with high viremia (HBV DNA > 2 × 105 IU/ml) showed inconsistent results. In addition, whether breastfeeding may cause MTCT of HBV is still a concern. We compared the MTCT rates in infants born to non-antiviral mothers with HBV DNA > 2 × 105 IU/ml with different delivery and feeding modes.

Methods

In total, 460 mothers with HBV DNA > 2 × 105 IU/ml and their 462 infants (2 twin sets) were included. Hepatitis B surface antigen (HBsAg) and antibodies against HBsAg (anti-HBs) in infants were quantitatively tested at 7–14 month age. Chi-square or Fisher’s exact tests was applied to analysis the MTCT rates with different delivery and feeding modes.

Results

Of the 462 infants, 214 (46.3%) were delivered by ECS and 178 (38.5%) were exclusively bottle-fed. Overall, 11 (2.4%) of 462 infants were HBsAg positive at 9.9 ± 2.4 month age. The MTCT rate (2.0%, 5/248) in vaginally delivered infants was similar to that (2.8%, 6/214) in infants delivered with ECS (χ2 = 0.307, p = 0.580), and the rate (3.2%, 9/284) in breastfed infants was also similar to that (1.1%, 2/178) in exclusively bottle-fed infants (χ2 = 2.190, p = 0.139). Moreover, the MTCT rates in infants with vaginal delivery and breastfed, ECS and breastfed, vaginal delivery and bottle-fed, and ECS and bottle-fed had no statistical significance, with 2.5%, 3.9%, 1.1%, and 1.1%, respectively (χ2 = 2.090, p = 0.538).

Conclusions

With timely immunoprophylaxis, ECS and bottle-feeding cannot reduce MTCT of HBV in infants born to high viremic mothers without antiviral therapy. ECS or bottle-feeding should not be recommended for the prevention of perinatal HBV infection.

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Background

Chronic hepatitis B virus (HBV) infection is still a major global health problem. Mother-to-child transmission (MTCT) of HBV is the main cause of HBV infection [1]. After the application of passive-active immunoprophylaxis in neonates of HBV-infected mothers, MTCT rates were decreased from 10 to 30% to fewer than 0.1% in infants born to hepatitis B e antigen (HBeAg)-negative mothers and from 70 to 90% to 5–10% in infants born to HBeAg-positive mothers, respectively [2,3,4]. In addition, antiviral therapy in pregnant women with high viral loads (HBV DNA > 2 × 105 IU/ml) or positive HBeAg during the third trimester can further reduce perinatal HBV infection [5]. Therefore, it is currently recommended that pregnant women with HBV DNA > 2 × 105 IU/ml or positive HBeAg take oral anti-HBV agents during the third trimester to reduce MTCT of HBV [6].

Breast milk is the optimal natural food for infants and breastfeeding is benefit for both mothers and infants. However, HBV DNA and hepatitis B surface antigen (HBsAg) may be detected in breast milks of HBV-infected women [7, 8]. Breastfeeding requires a long period of time, from several months to more than one year, with many times a day, during which breast lesions such as cracked or bleeding nipples are unavoidable. Moreover, lesions in the oral cavity of infants, such as surgery on short lingual frenulum, oral candidiasis, or other reasons, may facilitate the entry of HBV in breast milk into blood circulation of infants. Thus, a considerable proportion of physicians considered that infants of HBV-infected mothers should be bottle fed, rather than breastfeeding [9, 10], and many HBV-infected mothers did not breastfeed their infants and chose bottle-feeding [11, 12], although studies showed that breastfeeding has no additional risks for MTCT of HBV [13, 14].

It has been assumed that elective cesarean section (ECS) may reduce MTCT of HBV since 1978 [7]. Some studies showed that infants delivered by ECS had lower MTCT of HBV than vaginally delivered infants [15,16,17], but other studies showed that ECS did not decrease the MTCT [18, 19]. Thus, studies on the issue of whether ECS may prevent MTCT of HBV obtained inconsistent results, although no guideline recommends ECS as a measure to prevent the MTCT [20,21,22]. Additionally, previous studies included HBV-infected pregnant women who had varied HBV DNA levels, which made the interpretation of results complicated, because infants born to high or low viremic mothers have remarkably different perinatal HBV infection [2,3,4]. So far, whether infants who were vaginally delivered and received breastfeeding have additional risk for MTCT of HBV is less studied in carrier mothers with high viremia and non-antiviral therapy. In the present study, we compared the HBV infection rates in infants born to carrier mothers with HBV DNA > 2 × 105 IU/ml with different delivery and feeding modes to address this issue.

Methods

Study subjects

The present study was a secondary analysis of the data previously collected from two multicenter prospective cohort studies on the prevention of MTCT of HBV [4, 23]. Considering that MTCT rate is almost near to zero in infants born to carrier mothers with HBV DNA ≤ 2 × 105 IU/ml after the timely passive-active immunoprophylaxis [3, 4], and there was no HBV infection in infants of mothers in our previous studies [4, 24], we did not include mothers with HBV DNA ≤ 2 × 105 IU/ml and their infants in the present study, and thus, we only enrolled high viremic carrier mothers (Fig. 1). The subjects in group 1 were composed of 145 mothers and their 145 infants, who were the control group (no antiviral therapy before and during pregnancy) of a study to evaluate the safety and efficacy of telbivudine used in pregnant women with positive HBeAg to prevent MTCT of HBV [23]. These women delivered their infants from April 2012 to December 2013. The participants in group 2 comprised of 315 mothers, who did not receive antiviral therapy before and during the pregnancy and their 317 infants (2 twin sets) from a study to evaluate the protective efficacy of earlier use of passive-active immunoprophylaxis in preventing MTCT of HBV [4]. These women delivered their infants from January 2014 to December 2018. Thus, in total, 460 paired high viremic mothers with non-antiviral therapy and their 462 infants were included in the present investigation.

Fig. 1
figure 1

Flow of subject enrollment

Full size image

Vaginal delivery referred all delivery through vagina, including spontaneous vaginal delivery and instrumental vaginal delivery. The proportion of instrumental vaginal delivery in China is very small, generally lower than 2% [25]. Thus, we included instrumental vaginal delivery in vaginal delivery. Since our present study was a secondary analysis of the previous data and due to the screening of the enrolled cases, non-elective cesarean section was not involved in this study, and only ECS was included. Bottle feeding referred no breastfeeding at all after birth. Breast feeding included exclusive breast feeding and mixed feeding of breast milk and formula milk.

Assays for HBV markers

HBsAg, antibodies against HBsAg (anti-HBs), and HBeAg were quantitatively tested with microparticle enzyme immunoassay (Architect, Abbott, North Chicago) in the Nanjing Drum Tower Hospital. Infants who were positive for HBsAg and negative for anti-HBs were considered as immunoprophylaxis failure and HBV infection. Anti-HBs responses to hepatitis B vaccination were divided into four levels, anti-HBs < 10 mIU/ml (non-response), 10-99.9 (low-response), 100-999.9 (medium-response), ≥ 1000 (high-response) as previous classification [26,27,28]. Maternal HBV DNA was tested with a commercial real-time polymerase chain reaction (PCR) kit (ACON, Hangzhou, China).

Statistical analysis

Normally distributed continuous variables were presented as mean ± SD and compared by Student’s t test. Non-normally distributed continuous variables were presented as medians and ranges and compared by Mann-Whitney U test. Categorical variables were compared by Chi-square or Fisher’s exact tests. The HBsAg-positive rate and anti-HBs positive rate (≥ 10 mIU/ml), and the equality of proportion of those with different anti-HBs level range across different groups were compared by Fisher’s exact test or the Monte Carlo test. The anti-HBs were presented as geometric mean concentration (GMC) followed by minimum and maximum values and compared by Mann-Whitney U tests. HBV DNA level was expressed as a logarithm of measured value. All statistical analyses were conducted using SPSS 17.0 (SPSS, Inc., Chicago, IL, USA). P < 0.05 indicated statistically significant difference.

Results

General characteristics of study population

All enrolled 462 infants received hepatitis B immunoglobulin (HBIG, 100 IU) and the birth dose of hepatitis B vaccine (10 µg yeast recombinant HBsAg) within 24 h after birth, mostly (412 infants, 89.2%) within one hour [4, 23]. Infants were followed up at 9.9 ± 2.4 months and all received the two additional hepatitis B vaccine at the ages of 1 and 6 months, respectively. Of the infants, 248 (53.7%) were vaginally delivered and 214 others (46.3%) were delivered by ECS, and 284 (61.5%) were breastfed and 178 others (38.5%) were exclusively bottle-fed. Baseline characteristics of enrolled infants and paired mothers in vaginal delivery and breastfed, ECS and breastfed, vaginal delivery and bottle-fed, and ECS and bottle-fed are described in Table 1. Maternal HBV DNA, gestational age, gender ratio were each similar between different groups.

Table 1 General characteristic of infants and their mothers in different delivery modes and feeding patterns
Full size table

HBV infection in infants with different delivery and feeding patterns

Overall, 11 (2.4%) of all 462 infants were HBsAg positive at the follow-up, indicating immunoprophylaxis failure. The HBV infection rate (2.0%, 5/248) in infants with vaginal delivery was similar to that (2.8%, 6/214) in those with ECS (χ2 = 0.307, p = 0.580). In addition, The HBV infection rate in the breastfed group was also similar to that in the bottle-fed group (3.2% vs. 1.1%, χ2 = 2.190, p = 0.139).

To further clarify whether combination of different delivery and feeding patterns on the MTCT of HBV, we compared the HBV infection rates in the four groups with different delivery and feeding patterns. Because the expected count was less than 5 in the statistical process, Fisher’s exact test was applied to compare the HBsAg-positive rate, the anti-HBs ≥ 10 mIU/ml rate, and the Monte Carlo test to compare the equality of proportion of those with different anti-HBs level range across different groups. Table 2 shows that the MTCT of HBV in infants with vaginal delivery and breastfed, ECS and breastfed, vaginal delivery and bottle-fed, and ECS and bottle-fed were 2.5%, 3.9%, 1.1%, and 1.1%, respectively (χ2 = 2.090, p = 0.538). In addition, the anti-HBs response rates and antibody levels in these four children groups were also similar.

Table 2 HBV serologic markers in infants with different delivery modes and feeding patterns
Full size table

Discussion

The present study showed that, the HBV infection rates were similar in infants born to high viremic carrier and non-antiviral mothers with different delivery and feeding models after timely passive-active immunoprophylaxis against hepatitis B. The results demonstrate that vaginal delivery or breastfeeding, or even vaginal delivery plus breastfeeding, does not add additional risk for MTCT of HBV in infants born to mothers with HBV DNA > 2 × 105 IU/ml.

Despite passive and active immunization, MTCT of HBV is still an important cause of chronic HBV infection, especially in mothers with high viral load or positive HBeAg [3, 29, 30]. The previously reported that MTCT rate was 5–10% in infants born to high viremic mothers without antiviral therapy [2,3,4] or 7.0% in the review literature [31]. In our present study, the incidence of HBV infection in infants of high viremic mothers was 2.4%, which was lower than the above-mentioned infection rates. The probable reason appears to be associated with the immediate passive-active immunoprophylaxis, since 89.2% of the infants received HBIG and the birth-dose hepatitis B vaccine within one hour after birth. Other studies also showed that immediately neonatal immunoprophylaxis improved the protective efficacy against MTCT of HBV [32, 33]. Nevertheless, the finding that 2.4% infants underwent MTCT of HBV in the present study emphasizes the importance of antiviral prophylaxis during the third trimester in preventing MTCT of HBV. Before 2020, antiviral prophylaxis during pregnancy against MTCT of HBV was not routinely recommended, thus, we were able to enroll large number of high viremic pregnant women with HBV DNA > 2 × 105 IU/ml who did not take anti-HBV agents during pregnancy in our study. Since 2020, antiviral prophylaxis has been routinely recommended in pregnant women with HBV DNA > 2 × 105 (5.3 log10) IU/ml and/or positive HBeAg in China as well as worldwide [6, 20], and the coverage rate of antiviral prophylaxis is steadily increasing [34].

Because of the presence of HBsAg and HBV DNA in breast milk of HBsAg-positive mothers [7, 8], whether breastfeeding may increase the risk of MTCT of HBV, especially in high viremic individuals, is often concerned by mothers and physicians. In our present study, although all these mothers were advised to breastfeed their infants, 38.5% of them still completely gave up breastfeeding and took exclusive bottle-feeding. Because baby-friendly hospitals in China require all newborns to be breastfed, breastfeeding rate is nearly to 100% during the hospitalization. In a tertiary hospital, breastfeeding rates are observed at 100%, 96%, 93% and 83% at discharge, 42 day, 3 and 6 month postpartum, respectively [35]. Thus, the finding that a high proportion of women infected with HBV completely gave up breastfeeding indicates that these women still worried about the MTCT of HBV caused by breastfeeding. Indeed, other reports showed that as high as 65.0% of HBsAg-positive mothers concerned on the transmission of HBV by breastfeeding [36, 37], although the World Health Organization and other organizations recommend the infants of HBsAg-positive mother be breastfed [6, 20, 21]. In the present study, even born to carrier mothers with HBV DNA > 2 × 105 IU/ml, infants who were breastfed had a similar HBV infection rate as infants, compared to infants who were bottle-fed (3.2% vs. 1.1%, p = 0.139), which is in accordance with the results in other studies [13, 14]. Therefore, our results provide more evidence that breastfeeding is not a risk for MTCT of HBV. The mechanism may be associated with two factors. One is that human breast contains high concentration of lactoferrin, which can inhibit the infectivity of HBV [38] as well as other viruses [39, 40]. The other is that administration of hepatitis B vaccine and HBIG in neonates shortly after birth has provided the immunity to HBV in infants. Therefore, HBV carrier mothers, even with high viral load, can breastfeed their infants and do not need to worry about the breast milk-associated HBV transmission. The results will help both clinicians and parents to overcome the anxiety about MTCT of HBV caused by breastfeeding, and thus is valuable to increase breastfeeding rates among HBV-infected mothers.

ECS is considered as an effective method to reduce the risk for MTCT of some viruses such as HIV before the availability of antiretroviral therapy [41]. It is assumed that vaginally delivered neonates may swallow vaginal secretions and amniotic fluid, and undergo transplacental transmission of HBV due to repeated, forceful contractions of the uterus during laboring, leading to increased MTCT of HBV [15, 42]. On the other hand, ECS has the least microtransfusion from mother to expectant neonates by avoiding repeated contractions of the uterus [43]. Even so, neonates delivered by ECS are also inevitably exposed to HBV by contacting their mothers’ blood. Nevertheless, compared to those vaginally delivered, ECS delivered neonates may expose to fewer viruses. However, timely administration of both HBIG and hepatitis B vaccine may neutralize the maternally derived HBV before the viruses enter into the hepatocytes of neonates. In the present study, we found that the HBV infection rate in the infants delivered by ECS was similar to that in vaginally delivered infants (2.8% vs. 2.0%, P = 0.580). Moreover, the MTCT rate in vaginally delivered and breastfed infants was also similar to the rate in ECS-delivered and bottle-fed infants (Table 2). Therefore, our results demonstrate that ECS cannot reduce MTCT of HBV even in infants born to high viremic carrier mothers. Considering the complications associated with ECS, vaginal delivery should be encouraged, regardless of mothers’ HBV DNA levels. These results will be helpful to alleviate the anxiety about MTCT of HBV caused by vaginal delivery and to reduce the unnecessary cesarean sections in HBV-infected pregnant women. ECS should be selected based on the obstetric indications, but should not be used to reduce MTCT of HBV.

There are several limitations in the present study. One is that although the data were collected from two prospective studies, the participants were not randomly assigned in the different groups. Another is that due to the screening of the enrolled cases, non-elective cesarean section was not involved in this study, which made the results a little incomplete. The third is that we administered HBIG and hepatitis B vaccine in most (89.2%) of neonates within one hour after birth, which is much earlier than the currently recommended use within 12 h after birth. This may be a limit to the external validity for settings where immunoprophylaxis is not promptly accessed. However, in our previously retrospective study, in which HBIG and hepatitis B vaccine were used within 24 h after birth, ECS did not reduce MTCT of HBV [19] and breastfeeding did not increase MTCT of HBV [13].

Conclusion

In conclusion, with timely passive and active immunoprophylaxis against hepatitis B, ECS or bottle-feeding should not be used for the prevention of perinatal HBV infection. Hence, vaginal delivery and breastfeeding should be recommended in HBV carrier pregnant women, even in maternal HBV DNA > 2 × 105 IU/ml and non-antiviral mothers. Nevertheless, maternal antiviral prophylaxis in pregnant women with HBV DNA > 2 × 105 IU/ml is required to prevent MTCT of HBV.

Data availability

The data support the findings of this study are available on reasonable request from the corresponding author.

Abbreviations

MTCT:

Mother-to-Child Transmission

HBV:

Hepatitis B Virus

ECS:

Elective Cesarean Section

HBsAg:

Hepatitis B Surface Antigen

Anti-HBs:

Antibodies Against HBsAg

HBeAg:

Hepatitis B e antigen

IRB:

Institutional review boards

PCR:

Polymerase Chain Reaction

GMC:

Geometric Mean Concentration

HBIG:

Hepatitis B Immunoglobulin

References

  1. Seto WK, Lo YR, Pawlotsky JM, Yuen MF. Chronic hepatitis B virus infection. Lancet. 2018;392:2313–24. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/S0140-6736(18)31865-8.

    Article  PubMed  Google Scholar 

  2. Wen WH, Huang CW, Chie WC, Yeung CY, Zhao LL, Lin WT, et al. Quantitative maternal hepatitis B surface antigen predicts maternally transmitted hepatitis B virus infection. Hepatology. 2016;64:1451–61. https://doiorg.publicaciones.saludcastillayleon.es/10.1002/hep.28589.

    Article  CAS  PubMed  Google Scholar 

  3. Cheung KW, Seto MTY, Kan ASY, Wong D, Kou KO, So PL, et al. Immunoprophylaxis failure of infants born to hepatitis B carrier mothers following routine vaccination. Clin Gastroenterol Hepatol. 2018;16:144–5. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/j.cgh.2017.07.013.

    Article  PubMed  Google Scholar 

  4. Huang H, Xu C, Liu L, Chen L, Zhu X, Chen J, et al. Increased protection of earlier use of immunoprophylaxis in preventing perinatal transmission of hepatitis B virus. Clin Infect Dis. 2021;73:e3317–23. https://doiorg.publicaciones.saludcastillayleon.es/10.1093/cid/ciaa898.

    Article  CAS  PubMed  Google Scholar 

  5. Funk AL, Lu Y, Yoshida K, Zhao T, Boucheron P, van Holten J, et al. Efficacy and safety of antiviral prophylaxis during pregnancy to prevent mother-to-child transmission of hepatitis B virus: a systematic review and meta-analysis. Lancet Infect Dis. 2021;21:70–84. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/S1473-3099(20)30586-7.

    Article  CAS  PubMed  Google Scholar 

  6. Zhou YH, Hu Y, Liu X, Yang H. CSOG MFM committee guideline: management of hepatitis B during pregnancy and prevention of Mother-to-Child transmission of hepatitis B virus (2020). Maternal Fetal Med. 2021;3:7–17.

    Article  CAS  Google Scholar 

  7. Lee AK, Ip HM, Wong VC. Mechanisms of maternal-fetal transmission of hepatitis B virus. J Infect Dis. 1978;138:668–71. https://doiorg.publicaciones.saludcastillayleon.es/10.1093/infdis/138.5.668.

    Article  CAS  PubMed  Google Scholar 

  8. Huang H, Ning M, Feng J, Chen J, Dai Y, Hu Y, et al. Hepatitis B viral markers in the human milk of HBsAg-Positive mothers: an observational study. J Hum Lact. 2022;38:298–308. https://doiorg.publicaciones.saludcastillayleon.es/10.1177/08903344211043066.

    Article  PubMed  Google Scholar 

  9. Giles ML, Garland SM, Grover SR, Lewin SM, Hellard ME. Impact of an education campaign on management in pregnancy of women infected with a blood-borne virus. Med J Aust. 2006;184:389–92. https://doiorg.publicaciones.saludcastillayleon.es/10.5694/j.1326-5377.2006.tb00288.x.

    Article  PubMed  Google Scholar 

  10. Ahn J, Salem SB, Cohen SM. Evaluation and management of hepatitis B in pregnancy: a survey of current practices. Gastroenterol Hepatol (N Y). 2010;6:570–8.

    PubMed  Google Scholar 

  11. Tong Leung VK, Lao TT, Suen SS, Chan OK, Singh Sahota D, Lau TK, et al. Breastfeeding initiation: is this influenced by maternal hepatitis B infection? J Matern Fetal Neonatal Med. 2012;25:2390–4. https://doiorg.publicaciones.saludcastillayleon.es/10.3109/14767058.2012.697941.

    Article  PubMed  Google Scholar 

  12. Kamgaing EK, Rogombe SM, Mikolo A-ML, Maniaga RK, Nkama E-MM, Ngoungou EB, et al. Management and development of newborns from mothers carrying HBsAg at the El Rapha polyclinic in Libreville, Gabon. Open J Pediatr. 2021;11:468–78.

    Article  Google Scholar 

  13. Chen X, Chen J, Wen J, Xu C, Zhang S, Zhou YH, et al. Breastfeeding is not a risk factor for mother-to-child transmission of hepatitis B virus. PLoS ONE. 2013;8:e55303. https://doiorg.publicaciones.saludcastillayleon.es/10.1371/journal.pone.0055303.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Zhou M, Li L, Han L, Sun F, Yi N. Breast-Feeding is not a risk factor of Mother-to-Child transmission of hepatitis B virus. Int J Gen Med. 2021;14:1819–27. https://doiorg.publicaciones.saludcastillayleon.es/10.2147/IJGM.S289804.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Pan CQ, Zou HB, Chen Y, Zhang X, Zhang H, Li J, et al. Cesarean section reduces perinatal transmission of hepatitis B virus infection from hepatitis B surface antigen-positive women to their infants. Clin Gastroenterol Hepatol. 2013;11:1349–55. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/j.cgh.2013.04.026.

    Article  PubMed  Google Scholar 

  16. He R, Wen P, Xiong M, Fan Z, Li F, Luo D, et al. Cesarean section in reducing mother-to-child HBV transmission: a meta-analysis. J Matern Fetal Neonatal Med. 2022;35:3424–32. https://doiorg.publicaciones.saludcastillayleon.es/10.1080/14767058.2020.1819229.

    Article  PubMed  Google Scholar 

  17. Forna L, Lupu A, Bozomitu L, Paduraru G, Cojocariu C, Anton C, et al. Identifying childhood risk factors for hepatitis B with a focus on vertical transmission. Diseases. 2024;12:215. https://doiorg.publicaciones.saludcastillayleon.es/10.3390/diseases12090215.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. Xu H, Zeng T, Liu JY, Lei Y, Zhong S, Sheng YJ, et al. Measures to reduce mother-to-child transmission of hepatitis B virus in China: a meta-analysis. Dig Dis Sci. 2014;59:242–58. https://doiorg.publicaciones.saludcastillayleon.es/10.1007/s10620-013-2918-0.

    Article  PubMed  Google Scholar 

  19. Hu Y, Chen J, Wen J, Xu C, Zhang S, Xu B, et al. Effect of elective Cesarean section on the risk of mother-to-child transmission of hepatitis B virus. BMC Pregnancy Childbirth. 2013;13:119. https://doiorg.publicaciones.saludcastillayleon.es/10.1186/1471-2393-13-119.

    Article  PubMed  PubMed Central  Google Scholar 

  20. World Health Organization. (2020). Prevention of mother-to-child transmission of hepatitis B virus: guidelines on antiviral prophylaxis in pregnancy. 2020. https://apps.who.int/iris/bitstream/handle/10665/333391/9789240002708-eng.pdf?sequence=1%26isAllowed=y

  21. Kumar M, Abbas Z, Azami M, Belopolskaya M, Dokmeci AK, Ghazinyan H, et al. Asian Pacific association for the study of liver (APASL) guidelines: hepatitis B virus in pregnancy. Hepatol Int. 2022;16:211–53. https://doiorg.publicaciones.saludcastillayleon.es/10.1007/s12072-021-10285-5.

    Article  PubMed  Google Scholar 

  22. European Association for the Study of the Liver. EASL clinical practice guidelines on the management of liver diseases in pregnancy. J Hepatol. 2023;79:768–828. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/j.jhep.2023.03.006.

    Article  Google Scholar 

  23. Hu Y, Xu C, Xu B, Hu L, Liu Q, Chen J, et al. Safety and efficacy of Telbivudine in late pregnancy to prevent mother-to-child transmission of hepatitis B virus: A multicenter prospective cohort study. J Viral Hepat. 2018;25:429–37.

    Article  CAS  PubMed  Google Scholar 

  24. Xu B, Xu C, Feng J, Chen J, Rui Y, Qiu Z, et al. Reduced mother-to-child transmission of hepatitis B after implementation of completely charge-free active-passive immunoprophylaxis: an observational cohort study. Expert Rev Vaccines. 2021;20:899–905. https://doiorg.publicaciones.saludcastillayleon.es/10.1111/jvh.12834.

    Article  CAS  PubMed  Google Scholar 

  25. Zhang Y, Gu N, Wang Z, Zheng M, Hu Y, Dai Y. Use of the 10-Group classification system to analyze how the population control policy change in China has affected Cesarean delivery. Int J Gynaecol Obstet. 2017;138:158–63. https://doiorg.publicaciones.saludcastillayleon.es/10.1002/ijgo.12210.

    Article  PubMed  Google Scholar 

  26. Lo KJ, Lee SD, Tsai YT, Wu TC, Chan CY, Chen GH, et al. Long-term immunogenicity and efficacy of hepatitis B vaccine in infants born to HBeAg-positive HBsAg-carrier mothers. Hepatology. 1988;8:1647–50. https://doiorg.publicaciones.saludcastillayleon.es/10.1002/hep.1840080629.

    Article  CAS  PubMed  Google Scholar 

  27. Wu JS, Hwang LY, Goodman KJ, Beasley RP. Hepatitis B vaccination in high-risk infants: 10-year follow-up. J Infect Dis. 1999;179:1319–25. https://doiorg.publicaciones.saludcastillayleon.es/10.1086/314768.

    Article  CAS  PubMed  Google Scholar 

  28. Zhang X, Zou H, Chen Y, Zhang H, Tian R, Meng J, et al. The effects of increased dose of hepatitis B vaccine on mother-to-child transmission and immune response for infants born to mothers with chronic hepatitis B infection: a prospective, multicenter, large-sample cohort study. BMC Med. 2021;1:148. https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12916-021-02025-1.

    Article  CAS  Google Scholar 

  29. Park JS, Pan CQ. Viral factors for HBV mother-to-child transmission. Hepatol Int. 2017;11:476–80. https://doiorg.publicaciones.saludcastillayleon.es/10.1007/s12072-017-9825-y.

    Article  PubMed  Google Scholar 

  30. Lu Y, Song Y, Zhai X, Zhu F, Liu J, Chang Z, et al. Maternal hepatitis B e antigen can be an indicator for antiviral prophylaxis of perinatal transmission of hepatitis B virus. Emerg Microbes Infect. 2021;10:555–64. https://doiorg.publicaciones.saludcastillayleon.es/10.1080/22221751.2021.1899055.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Visvanathan K, Dusheiko G, Giles M, Wong ML, Phung N, Walker S, et al. Managing HBV in pregnancy. Prevention, prophylaxis, treatment and follow-up: position paper produced by Australian, UK and new Zealand key opinion leaders. Gut. 2016;65:340–50. https://doiorg.publicaciones.saludcastillayleon.es/10.1136/gutjnl-2015-310317.

    Article  CAS  PubMed  Google Scholar 

  32. Jourdain G, Ngo-Giang-Huong N, Harrison L. iTAP study group. Tenofovir to prevent perinatal transmission of hepatitis B. N Engl J Med. 2018;378:2350. https://doiorg.publicaciones.saludcastillayleon.es/10.1056/NEJMc1805396.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Liang Q, Li N, Song S, Wei Q, Ma C, Li K, et al. Impact of timing on protection of combined immunoprophylaxis in preventing mother-to-child transmission of hepatitis B virus: a retrospective study. J Matern Fetal Neonatal Med. 2023;36:2257837. https://doiorg.publicaciones.saludcastillayleon.es/10.1080/14767058.2023.2257837.

    Article  PubMed  Google Scholar 

  34. Tang J, Xiang K, Zhou Y-H. Making elimination of perinatal hepatitis B infection a reality: the Chinese contribution. Maternal Fetal Med. 2024;6:67–9. https://doiorg.publicaciones.saludcastillayleon.es/10.1097/FM9.0000000000000213.

    Article  Google Scholar 

  35. Liu Y, Xiang J, Yan P, Liu Y, Chen P, Song Y, et al. Trajectory of breastfeeding among Chinese women and risk prediction models based on machine learning: a cohort study. BMC Pregnancy Childbirth. 2024;24:858. https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12884-024-07010-z.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Zhang L, Gui X, Fan J, Wang B, Ji H, Yisilafu R, et al. Breast feeding and immunoprophylaxis efficacy of mother-to-child transmission of hepatitis B virus. J Matern Fetal Neonatal Med. 2014;27:182–6. https://doiorg.publicaciones.saludcastillayleon.es/10.3109/14767058.2013.806901.

    Article  CAS  PubMed  Google Scholar 

  37. Pan YC, Jia ZF, Wang YQ, Yang N, Liu JX, Zhai XJ, et al. 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. J Viral Hepat. 2020;27:1032–43. https://doiorg.publicaciones.saludcastillayleon.es/10.1111/jvh.13314.

    Article  CAS  PubMed  Google Scholar 

  38. Luo Y, Xiang K, Liu J, Song J, Feng J, Chen J, et al. Inhibition of in vitro infection of hepatitis B virus by human breastmilk. Nutrients. 2022;14:1561. https://doiorg.publicaciones.saludcastillayleon.es/10.3390/nu14081561.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  39. Lai X, Yu Y, Xian W, Ye F, Ju X, Luo Y, et al. Identified human breast milk compositions effectively inhibit SARS-CoV-2 and variants infection and replication. iScience. 2022;25:104136. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/j.isci.2022.104136.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Xiang K, Zhou Y-H. Breastmilk—Old but not obsolete: from the safety of breastfeeding during the coronavirus disease 2019 pandemic to broad antiviral drug development. Maternal Fetal Med. 2023;5:69–70.

    Article  Google Scholar 

  41. Read JS, Newell MK. Efficacy and safety of Cesarean delivery for prevention of mother-to-child transmission of HIV-1. Cochrane Database Syst Rev. 2005;CD005479. https://doiorg.publicaciones.saludcastillayleon.es/10.1002/14651858.CD005479.

  42. Lee SD, Lo KJ, Tsai YT, Wu JC, Wu TC, Yang ZL, et al. Role of caesarean section in prevention of mother-infant transmission of hepatitis B virus. Lancet. 1988;2:833–4. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/s0140-6736(88)92792-4.

    Article  CAS  PubMed  Google Scholar 

  43. Lin HH, Kao JH, Hsu HY, Mizokami M, Hirano K, Chen DS. Least microtransfusion from mother to fetus in elective Cesarean delivery. Obstet Gynecol. 1996;87:244–8. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/0029-7844(95)00385-1.

    Article  CAS  PubMed  Google Scholar 

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Acknowledgements

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Funding

This work was supported by grants from the National Natural Science Foundation of China (81672002), Health Commission of Nanjing City (ZKX20021), Science and Technology Department of Jiangsu Province (BK20221169), and Jiangsu Province Center for Innovation in Obstetrics and Gynecology (CXZX202229), China.

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Authors and Affiliations

  1. Department of Infection Management, Wuxi Ninth People’s Hospital Affiliated to Soochow University, Wuxi, Jiangsu, 214000, China

    Hongyu Huang

  2. Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, 210008, China

    Yali Hu & Yimin Dai

  3. Departments of Laboratory Medicine and Infectious Diseases, Affiliated Hospital of Medical School, Jiangsu Key Laboratory for Molecular Medicine, Nanjing Drum Tower Hospital, Nanjing University, 321 Zhong Shan Road, Nanjing, Jiangsu, 210008, China

    Yi-Hua Zhou

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Contributions

Yi-Hua Zhou and Yali Hu contributed to the study conception and design. Material preparation, data collection and analysis were performed by Hongyu Huang and Yimin Dai. The first draft of the manuscript was written by Hongyu Huang and Yi-Hua Zhou and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Yi-Hua Zhou.

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Ethics approval and consent to participate

The present study was approved by the institutional review boards (IRB) of the Nanjing Drum Tower Hospital. As serum samples were collected in the previous studies, in which all mothers gave the written informed consent for their infants, the exemption of written informed consent was approved by the IRB of Nanjing Drum Tower Hospital in the present study.

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Huang, H., Hu, Y., Dai, Y. et al. Elective cesarean section and bottle-feeding do not reduce infection of hepatitis B in infants of high viremic mothers: a retrospective study. BMC Pregnancy Childbirth 25, 482 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12884-025-07606-z

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Keywords

BMC Pregnancy and Childbirth

ISSN: 1471-2393

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