Chronic hepatitis B virus (HBV) infection remains a major global health challenge, with 1.23 million new infections worldwide in 2022 [
1]. Mother-to-child transmission (MTCT) contributes substantially to chronic HBV infections; thus, primary prevention is important for achieving HBV elimination [
1]. In addition to active-passive HBV immunization of newborns, administration of tenofovir disoproxil fumarate to pregnant mothers with HBV DNA titer (≥200,000 IU/mL) effectively prevented MTCT [
2]. However, evidence supporting other preventive strategies, such as breastfeeding and cesarean section for preventing MTCT, remains insufficient.
A study by Ki et al. provided valuable large-scale, real-world longitudinal data regarding factors associated with MTCT [
3]. This population-based cohort study included HBV status data from 154,478 mothers-infant pairs from the Perinatal Hepatitis B Prevention Program (PHBPP) of South Korea from 2002–2021. Reimbursement records from the Korean National Health Insurance were merged with the PHBPP data to include antiviral prescriptions and delivery methods in the analysis. Maternal antiviral use, hepatitis B e antigen (HBeAg)-negative status, cesarean section, and breastfeeding were associated with lower MTCT rates.
The World Health Organization (WHO) and European Association for the Study of the Liver (EASL) recommend tenofovir prophylaxis for pregnant women with a high viral load [
4,
5]. This study by Ki et al. also showed a significantly lower MTCT rate with antiviral therapy (0.9% vs. 2.4%). Mothers with HBeAg, which was correlated with a high viral load, were found to be the most effective (1.0% vs. 5.9%). Unfortunately, the maternal HBV DNA titer was unavailable, and risk stratification based on the titer level was impossible. The MTCT rates were similar between the initiation of antiviral therapy at weeks 14–27 (0.39%) and 28–32 (0.44%). This is comparable to a recent randomized trial in which maternal tenofovir prophylaxis from week 16 with infant HBV immunization was non-inferior to the initiation of at tenofovir week 28 with the administration of HBV immunoglobulin and vaccination after birth [
6].
This study addressed whether cesarean section can reduce the risk of MTCT. The authors reported that cesarean section showed a lower MTCT risk than vaginal delivery, even after adjusting for other variables (1.9% vs. 2.6%). However, this should be interpreted with caution because cesarean sections carry the risk of short- and long-term complications for the mother [
7]. He et al. suggested that cesarean section may be beneficial in reducing MTCT (pooled odds ratio 0.42, 95% confidence interval 0.23–0.76) [
8]; however, another single center prospective cohort study showed no statistical difference in MTCT rate between delivery methods [
9]. Cesarean section has been reported to reduce MTCT in mothers with HBV DNA levels ≥200,000 IU/mL [
10], but since antiviral therapy effectively lowers maternal viral load, it may be sufficient to prevent MTCT without the need for cesarean delivery. The EASL recommended that cesarean section may be beneficial for high HBV titers and HBeAg-positive Asian mothers in 2023 [
11], but no recommendations were provided about cesarean section in their most recent guidelines [
5].
Concerns about the transmission of HBV through breast milk often hinder breastfeeding postpartum. However, breastfeeding was shown to be safe if active-passive immunization performed for infants [
12]. Moreover, this study shows breastfeeding may be beneficial in reducing MTCT compared to formula feeding (1.8% vs. 2.8%). Pan et al. found that breastfeeding modestly reduces MTCT (relative risk 0.74; 95% confidence interval 0.56–0.98) [
9], supporting the protective effect of breastfeeding. Luo et al. showed that lactoferrin in breast milk binds to hepatitis B surface antigen and inhibits HBV [
13]. Breastfeeding is known to protect infants against human immunodeficiency virus vertical transmission through multiple factors, such as healthy microbiome, lactoferrin, elafin, and other innate immune factors, which may apply to HBV [
14]. However, precautionary measures should be considered if mothers have cracked nipples or infants with oral ulcers.
Fortunately, the rate of MTCT has decreased over time from 3.6% (2002–2005) to 1.3% (2018–2021). The authors stated that older maternal age and the use of antiviral prophylaxis may have contributed to this trend. The rate of cesarean section is steadily increasing in South Korea, from 36.9% in 2012 to 58.7% in 2021 [
15]. Improvement in socioeconomic status, multiple gestations induced by fertility treatments, and obesity may have contributed to an increase in cesarean sections. As cultural backgrounds and societies differ globally, the generalizability of the findings may be limited. Nonetheless, this research supports progress toward the WHO’s goal of eliminating HBV.
FOOTNOTES
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Authors’ contribution
Conception or design of the work: E. Choi and Y-S. Lee; Drafting the article: E. Choi and Y-S. Lee; Critical revision of the article: E. Choi and J.H. Lee; Final approval of the version to be published: Y-S. Lee.
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Acknowledgements
This study was supported by a National Research Foundation of Korea grant from the Korean government (the Ministry of Education, Science and Technology, RS-2021-NR061523), a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), South Korea funded by the Ministry of Health & Welfare, Republic of Korea (RS-2024-00439963), and Korea University Guro Hospital (KOREA RESEARCHDRIVEN HOSPITAL) and Korea University (K2512711).
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Conflicts of Interest
The authors have no conflicts of interest to declare.
Abbreviations
European Association for the Study of the Liver
hepatitis B envelope antigen
mother-to-child transmission
Perinatal Hepatitis B Prevention Program
World Health Organization
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Citations
Citations to this article as recorded by
- Reply to correspondence on “Factors associated with hepatitis B mother-to-child transmission in a national prevention program”
Eunho Choi, Ji Hoon Kim, Young-Sun Lee
Clinical and Molecular Hepatology.2026; 32(2): e262. CrossRef - Redefining MTCT prevention strategies toward HBV elimination: Correspondence to editorial on “Factors associated with hepatitis B mother-to-child transmission in a national prevention program”
Moran Ki, Jong-Hyun Kim
Clinical and Molecular Hepatology.2026; 32(2): e224. CrossRef
