Abstract
To inform WHO guidelines, we conducted a systematic review and meta-analysis to assess maternal and perinatal outcomes comparing cesarean section (c-section) before labor and rupture of membranes [elective c-section (ECS)] with other modes of delivery for women living with HIV. We searched PubMed, CINAHL, Embase, CENTRAL, and previous reviews to identify published trials and observational studies through October 2015. Results were synthesized using random-effects meta-analysis, stratifying for combination antiretroviral therapy (cART), CD4/viral load (VL), delivery at term, and low-income/middle-income countries. From 2567 citations identified, 36 articles met inclusion criteria. The single randomized trial, published in 1999, reported minimal maternal morbidity and significantly fewer infant HIV infections with ECS [odds ratio (OR) 0.2, 95% confidence interval (CI) 0.0-0.5]. Across observational studies, ECS was associated with increased maternal morbidity compared with vaginal delivery (OR 3.12, 95% CI 2.21-4.41). ECS was also associated with decreased infant HIV infection overall (OR 0.43, 95% CI 0.30-0.63) and in low-income/middle-income countries (OR 0.27, 95% CI 0.16-0.45), but not among women on cART (OR 0.82, 95% CI 0.47-1.43) or with CD4 cell count more than 200/VL less than 400/term delivery (OR 0.59, 95% CI 0.21-1.63). Infant morbidity moderately increased with ECS. Although ECS may reduce infant HIV infection, this effect was not statistically significant in the context of cART and viral suppression. As ECS poses other risks, routine ECS for all women living with HIV may not be appropriate. Risks and benefits will differ across settings, depending on underlying risks of ECS complications and vertical transmission during delivery. Understanding individual client risks and benefits and respecting women's autonomy remain important.
Highlights
Cesarean section (c-section) before labor and before rupture of membranes [elective c-section (ECS)] has been suggested as an intervention to prevent vertical transmission of HIV in high-income settings where training and resources exist to conduct c-sections safely [1]
ECS was associated with increased maternal morbidity compared with vaginal delivery
ECS was associated with decreased infant HIV infection overall and in low-income/middle-income countries, but not among women on combination antiretroviral therapy (cART) or with CD4þ cell count more than 200/VL less than 400/term delivery
Summary
Cesarean section (c-section) before labor and before rupture of membranes [elective c-section (ECS)] has been suggested as an intervention to prevent vertical transmission of HIV in high-income settings where training and resources exist to conduct c-sections safely [1]. The decision to offer ECS to women living with HIV must aDepartment of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA, and bDepartment of Reproductive Health and Research, World Health Organization, including the UNDP, UNFPA, UNICEF, WHO, World Bank, Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Geneva, Switzerland. PhD, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Room E5547, Baltimore, MD 21205, USA
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