C-Sections Help Prevent HIV Transmission to Infants, But May Increase Future Health Risks

JULY 24, 2017
Carolyn Colwell
Elective Cesarean Sections (ECS) may not be appropriate for all HIV mothers trying to prevent transmitting the infection to their babies, according to a recent study.

In general, ECS reduced HIV infections in infants by an odds ratio of 0.2. In low and middle-income countries (LMIC), the drop was by an odds ratio of 0.27.  However, that statistically significant reduction was not risk-free and did not carry over to women on anti-retroviral therapy (ART) and with low viral loads.

The meta-analysis based on a literature review found that risks associated with ECS varied by geographic regions, HIV viral load, disease stage, use of anti-retroviral treatment (ART), and the level of obstetric skills available.

“Unfortunately, many women in low-income and middle-income countries in particular lack access to high quality obstetric services, a critical concern in the context of rising c-section rates globally. Furthermore, women living with HIV may experience higher rates of some obstetric complications compared with HIV-uninfected women,” wrote the corresponding author, Caitlin E. Kennedy PhD (pictured), associate professor at John Hopkins University’s Bloomberg School of Public Health.

An observational study of 501 women with HIV conducted in Kenya in 2014 revealed deaths among 8 HIV women out of 405 (.02%) who delivered vaginally, 5 of 74 (6.7%) who had non-ECS, and none of the 22 given ECS. The only multi-country LIMC study (a prospective cohort in Argentina, Bahamas, Brazil and Mexico), found no statistically significant difference in overall maternal morbidities between HIV women who delivered by ECS or vaginally, the Kennedy team reported in their study.

However, in 2005 a Cochrane review of one clinical trial and 5 observational studies found a tradeoff between reduced mother-to-child HIV transmission with a slightly higher rate of post-partum maternal health conditions, most of which it described as minor, the Kennedy study said.

According to observational studies, the impact on infants delivered by ECS compared with vaginal delivery had increased odds ratios:  for respiratory distress syndrome (2.7 overall and 2.73 in LMICs only) and for transient tachyprea (3.17 overall and 7.10  in LIMCs only).

The overall statistics on benefits might be distorted by the populations studied. Most of the studies reviewed were conducted in European countries in addition to one in the US and 2 in the US and Puerto Rico. The data was further complicated by the fact that only 17 of the 36 articles included were published after 2005. The 36 articles were based on 17 studies, many of which had overlapping cohorts.

“In conclusion, our findings suggest that while ECS may be protective against infant HIV infection in the absence of effective ART, this effect was not statistically significant among women on cART or who are at term and virally suppressed, and there are other risks to mothers and infants associated with ECS,” the study said.

Consequently, the Kennedy team wrote that according to their findings routine ECS for women with HIV may not be appropriate in all cases. US guidelines recommend ECS where women have higher viral loads. That is in keeping with guidelines from 23 European countries where vaginal delivery was recommended for women with HIV who were successfully treated with ART and had low viral loads, the study explained.

“Clinicians and healthcare providers should consider the risks and benefits for individual clients, and respect women’s autonomy to choose their mode of delivery,” the authors added.

While the study was funded by WHO, the study noted that its conclusions were the views and opinions of the co-authors and “not necessarily of the WHO."

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