Caesarean Delivery Reduces Mother to Child Transmission of AIDS

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HIV Transmission in Pregnant Women

Planned Caesarian section is a safe and effective method for preventing transmission of HIV from mother to child during birth for women who are not using antiretroviral medications, according to a new systematic review of studies.

For HIV-positive women with no other medical conditions, the risks of elective C-section, which include infection, are outweighed by the magnitude in the reduction of the transmission of the virus that causes AIDS, found study authors led by Jennifer S. Read, M.D., with the Pediatric, Adolescent, and Maternal AIDS Branch at the National Institute of Child Health and Human Development.

However, although the effectiveness of planned Caesarians in preventing mother-to-child transmission of human immunodeficiency virus-1 (HIV-1) has been know for some time, there are relatively few studies on the matter, or on how safe it is for the mother. In this review, the authors found only a single randomized control trial that was clinically relevant, along with five observational studies.

This review will appear in the current issue of The Cochrane Library, which is published by The Cochrane Collaboration, an international organization that evaluates medical research. These reviews evaluate best medical practices and are based on evidence from clinical studies, after the reviewers consider both the content and quality of medical studies on a given topic.

The primary study evaluated was conducted by the European Mode of Delivery Collaboration and published in The Lancet in 1999. In this study, 408 HIV-positive pregnant women were randomly assigned to have an elective Caesarian or to give birth vaginally. The women did not receive antiretroviral treatment or were taking only zidovudine (AZT).

Of the Caesarian births, there was a 3.5 percent rate of mother-to-child transmission, compared with 10.2 percent for vaginal deliveries.

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The five observational studies noted virus transmission rates and the incidence of post-birth complications in women who were HIV positive without having a say in what type of delivery occurred.

The benefit of a planned Caesarian section has been known since the 1990s, before the widespread use of antiretroviral treatments for HIV, the review notes.

Most HIV-positive pregnant women in developed countries now take several antiretroviral drugs, Read said. Women who are about to give birth receive preventive treatment with an antiretroviral agent before and during birth, which is also known to reduce the incidence of viral transmission. "Mother-to-child transmission is negligible now," Read said.

However, the study notes that mother-to-child transmission of HIV-1 is the most common cause of the infection in children worldwide, affecting more than 2,000 children each day. An estimated half million children died of AIDS in 2004, making reduction of the risk of maternal HIV-1 transmission an important global public health goal.

For women with poorly controlled HIV-1 infection and who have not received antiretroviral therapy, the review strongly suggests that the benefits of a planned Caesarian section outweigh the risks of postpartum problems due to surgical delivery.

To prevent viral transmission, the Caesarian must be planned to take place before the start of labor and before the rupture of membranes.

Because the risk of transmitting HIV-1 to a newborn is now so low, women are feeling more optimistic about giving birth, Read said. Not only are they more confident that they will not be risking the health of their children, they are more certain that they will be around to take to raise them.

However, it is still considered possible to transmit HIV-1 in breast milk and women in developed countries who are HIV-1 positive are strongly advised against breastfeeding. Two of the Cochrane reviewers were authors of two included studies.

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