https://orcid.org/0000-0002-0685-2218
Figures
Abstract
Introduction
Hepatitis B virus (HBV) is one of the major public health problems globally and needs an urgent response. It is one of the most responsible causes of mortality among the five hepatitis viruses, and it affects almost every class of individuals. Different studies were conducted on the prevalence of HBV among pregnant women in East African countries, but none of them showed the pooled prevalence of HBV among the pregnant women. Thus, the main objective of this study was to determine the pooled prevalence and its determinants among pregnant women in East Africa.
Methods
We searched studies using PubMed, Scopus, Embase, ScienceDirect, Google Scholar and grey literature that were published between January 01/2020 to January 30/2024. The studies were assessed using the Newcastle Ottawa Scale (NOS) quality assessment scale. The random-effect (DerSimonian) model was used to determine the pooled prevalence and associated factors of HBV among pregnant women. Heterogeneity were assessed by I2 statistic, sub-group analysis, and sensitivity analysis. Publication bias was assessed by Egger test, and the analysis was done using STATA version 17.
Result
A total of 45 studies with 35639 pregnant women were included in this systematic review and meta-analysis. The overall pooled prevalence of HBV among pregnant women in East Africa was 6.0% (95% CI: 6.0%−7.0%, I2 = 89.7%). The highest prevalence of 8% ((95% CI: 6%, 10%), I2 = 91.08%) was seen in 2021, and the lowest prevalence 5% ((95% CI: 4%, 6%) I2 = 52.52%) was observed in 2022. A pooled meta-analysis showed that history of surgical procedure (OR = 2.14 (95% CI: 1.27, 3.61)), having multiple sexual partners (OR = 3.87 (95% CI: 2.52, 5.95), history of body tattooing (OR = 2.55 (95% CI: 1.62, 4.01)), history of tooth extraction (OR = 2.09 (95% CI: 1.29, 3.39)), abortion history(OR = 2.20(95% CI: 1.38, 3.50)), history of sharing sharp material (OR = 1.88 (95% CI: 1.07, 3.31)), blood transfusion (OR = 2.41 (95% CI: 1.62, 3.57)), family history of HBV (OR = 4.87 (95% CI: 2.95, 8.05)) and history needle injury (OR = 2.62 (95% CI: 1.20, 5.72)) were significant risk factors associated with HBV infection among pregnant women.
Conclusions
The pooled prevalence of HBV infection among pregnant women in East Africa was an intermediate level and different across countries ranging from 1.5% to 22.2%. The result of this pooled prevalence was an indication of the need for screening, prevention, and control of HBV infection among pregnant women in the region. Therefore, early identification of risk factors, awareness creation on the mode of transmission HBV and implementation of preventive measures are essential in reducing the burden of HBV infection among pregnant women.
Citation: Yirsaw BG, Agimas MC, Alemu GG, Tesfie TK, Derseh NM, Abuhay HW, et al. (2024) Prevalence of Hepatitis B virus infection and its determinants among pregnant women in East Africa: Systematic review and Meta-analysis. PLoS ONE 19(7): e0307102. https://doi.org/10.1371/journal.pone.0307102
Editor: Isabelle Chemin, Centre de Recherche en Cancerologie de Lyon, FRANCE
Received: April 26, 2024; Accepted: June 28, 2024; Published: July 12, 2024
Copyright: © 2024 Yirsaw et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting Information files.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Abbreviations: CI, confidence interval; HBV, hepatitis B virus; OR, odds ratio; WHO, world health organizations; ELISA, enzyme-linked immunosorbent assay
Introduction
Globally, hepatitis B virus (HBV) is one of the major public health problems that can cause both acute and chronic diseases [1–3], and that requires an urgent response.
Among the five viruses (hepatitis A, B, C, D, and E virus), which are responsible for most cases of viral hepatitis, HBV and hepatitis C virus cause 96% of the mortality from these viral hepatitis. In 2015, around 257 million people were living with the Hepatitis B virus, and among these, 68% of the infected persons were from Africa and Western Pacific regions [4]. Specifically, the burden of the HBV is still high in eastern African countries, and it needs the implementation of universal and free HBV vaccination for all adults in the region [5].
Sero-positivity with HBV in pregnant women can transmit the disease to an unborn child during pregnancy. From a total of the world’s population, 25.3% are women reproductive age. Of those chronically infected, there are 65 million women who are of childbearing age who can potentially transmit HBV to their babies [4].
Results showed that, the prevalence of HBV among pregnant women is still high according to the WHO classification [1, 6]. The pooled prevalence of HBV among pregnant women in Ethiopia 4.7% [7] and 4.75% [8] which is an intermediate level of HBV, but individual studies showed that the prevalence is still beyond these pooled values[9–11].
So many studies have been conducted on the prevalence of the HBV among pregnant women in each East African country separately. For each separate study different key risk factors were identified for pregnant women, like abortion history [12–23]), History of multiple sexual partners ([1, 15, 18, 19, 21–30], surgical procedure [14, 24, 26, 31], History of hospitalization [2, 10, 12, 15, 16, 19, 20, 31, 32], traditional tonsillectomy [1, 2, 19], history of sexually transmitted infection [2, 30], human immunodeficiency virus (HIV) [2, 10, 16, 29, 33], alcohol drinking [2, 15], history of blood transfusion [14, 16–18, 21, 29, 34–37], knowledge about HBV [34], female genital mutilation [24, 34], frequency of testing & screening [34], tattooing[1, 10, 13, 21, 25, 28, 29, 31, 35], tooth extraction/dental therapy [14, 15, 24, 28, 31, 35], History of home delivery, insufficient knowledge and working at health facility [10], sharing sharp materials [10, 25, 26], history of vulvar ulcer [36], history of contact with patients who had jaundice [1, 36], history of contact with liver disease person[15], the age of the pregnant women [16, 29], education [17, 29], family history of HBV [17, 25, 26, 29, 32], Parity [17, 33], home delivery by traditional birth attendants [18] were significant risk factors for HBV infection among pregnant women. But on the other side, different studies showed risk factors such as: multiple sexual partners [38–41], HIV serostatus [38], history of blood transfusion [38, 39, 41], surgical procedure [39, 41], hospital admission, genital mutilation, body tattooing, and history of previous birth delivery [39], history of abortion and History of sharing sharp materials [40], history of dental procedure [41] were not statistically significant risk factors for HBV infection among pregnant women. Therefore, results showed inconsistent outputs on the risk factors for HBV among pregnant women, and therefore, this study figured out the key risk factors for HBV among pregnant women using systematic and meta-analyses in East Africa. This could contribute a significant role to achieve the sustainable development goal 3, which focuses on fighting communicable diseases such as HBV to eliminate viral hepatitis by 2030[4].
But to the best of the researchers knowledge, there was no study conducted using systematic review and meta-analysis for the prevalence of the HBV and its determinants among pregnant women in East Africa.
Thus, the objective of this study was to determine the pooled prevalence and its determinants among pregnant women in this area.
Methods
Study protocol and registration
This study was conducted on the prevalence of HBV and its determinants among pregnant women in East Africa, and conducted following guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). The study has been registered on the International Prospective Register of Systematic Review (PROSPERO), with registration number CRD42024512759.
Searching strategy
We searched studies that were published between January 01/2020 to January 30/2024 using electronic databases such as PubMed, Scopus, Embase, ScienceDirect, Google Scholar, and other sources. Key words like Hepatitis B, prevalence, determinants and East Africa with their corresponding Medical Subject Headings (MeSH) terms were used to search by combining using Boolean operators (AND, OR, NOT). For instance, the advanced PubMed search strategy was: (((Hepatitis B OR Hepatitis B virus OR HBV OR Hepatitis OR Hepatitis B Virus Infection) AND (Prevalence OR Magnitude OR Proportion OR Burden OR Epidemiology)) AND (Determinants OR Predictor OR Risk Factor OR Associated Factor OR Related Factor)) AND (East Africa OR Eastern Africa OR Eritrea OR Ethiopia OR Djibouti OR South Sudan OR Rwanda OR Uganda OR Burundi OR Malawi OR Zimbabwe OR Zambia OR Mozambique OR Madagascar OR Mauritius OR Comoros OR Tanzania OR Seychelles OR Kenya OR Somalia) and Filters applied: from 2020/1/1–2024/1/30.
Article selection and eligibility criteria
The following types of papers were taken into account for this systematic review and meta-analysis: full text articles, abstracts, and thesis or dissertations that were written only in English, all observational studies that report the prevalence of HBV among pregnant women, outcome ascertainment using rapid test and ELISA methods of diagnostics, the publication year between January 01/2020 to January 30/2024 were included.
Duplicate studies, research done in languages other than English, review articles, and studies conducted before 01/2020 and after 30/2024 were not included in this analysis.
Outcome of the study
The primary outcome of the study was to determine the pooled prevalence of HBV infection among pregnant women in East Africa, and the secondary outcome of the study was to identify the determinant factors associated with HBV infection among pregnant women in East Africa.
Data extraction
The data were extracted using a Microsoft Excel spreadsheet by three authors independently (TKT, NMD and GGA). The extracted data were: author names, year of publication, study’s conducted area, study design, sampling technique, outcome ascertainment, total number of participants (samples), number of HBV infected pregnant women, prevalence, and variables related to the prevalence of HBV were also extracted.
Quality appraisal
Each study quality was discussed and assessed by two independent reviewers (MCA and GAY), and if any deviations arose between these two, the third reviewer (BGY) intervened and a consensus was reached. The studies were assessed using the Newcastle Ottawa Scale (NOS) quality assessment scale [42] and the criteria were representativeness of the sample, sample size, non-response rate, outcome ascertainment, and comparability of the study. The quality assessment was determined by providing a numerical score, with scores 8–9 considered excellent quality, 6–7 very good quality, 4–5 good quality, and below 4 considered poor quality or unsatisfactory, and hence numerical value below 4 excluded from the study (S1 Table in S1 File).
Statistical analysis and synthesis
The random-effect (DerSimonian) model was used to determine the pooled prevalence and associated factors of HBV infection among pregnant women in East Africa. For those different studies, heterogeneity was assessed by I2 statistic, and furthermore, sub-group analysis, and sensitivity analysis were used to analyses potential sources of heterogeneity. The value of I2 statistic was an indication of variation across studies, and values of 25%, 50% and 75% were indications of low, medium and high presence of heterogeneity [43]. We assessed the publication bias using the Egger test, and p-values less than 0.05 were an indication of a significant presence of publication bias [44]. As the asymmetry was detected using the funnel plot and Egger’s test; the trim-and-fill method was used to re-estimate the pooled effect size by removing the outlying effect sizes, and then added back into the funnel plot and mirrored on the opposite side to identify the best estimate of the unbiased pooled effect size [45]. The analysis was done using statistical software, STATA version 17.
Results
Searching results and included studies
This systematic review and meta-analysis was conducted on the prevalence of HBV and its determinants among pregnant women in East Africa. All studies about the prevalence of HBV among pregnant women were included, and different searching strategies were developed for different databases and a total of 1187 recorded studies 960 from databases, and 227 from other sources were identified. From a total of 960 studies searched using databases, 304 articles were removed before screening because of duplicating, 601 articles removed using titles and abstracts reviews, 1 article was removed due to ambiguity and 20 articles were multiple reports of the same result. From a total of 227 studies searched via other methods, 104 studies were not relevant, 67 studies were not related to the topic, and 45 studies were published before 2020. Finally, 45 studies with a total of 35639 pregnant women (around 792 average pregnant women) were included for systematic and meta-analysis (Fig 1).
Characteristics included studies
The studies were conducted in East African countries between 2020 and 2024. 91.11% of the included articles were institutional based cross-sectional studies. The minimum number of pregnant women participated in a study was 124 [12] and the maximum number was 12138 [25]. (Table 1).
With regard to publication year, from a total of 45 studies, 9 [10, 18, 19, 24, 28–30, 38, 47] were in 2020, 12 [9, 11, 13, 16, 22, 26, 27, 36, 48–51] in 2021, 14 [12, 14, 15, 20, 21, 23, 31, 32, 37, 39, 40, 52–54] in 2022, and 10 [1, 2, 17, 25, 33–35, 41, 55, 56] in 2023. More than two-third, thirty one (68.89%) of studies were conducted in Ethiopia, three (6.67%) in Uganda, three (6.67%) in Somalia, two (4.44%) in South Sudan, two (4.44%) in Tanzania, one in Djibouti, one in Zimbabwe, one in Mozambique, and one in Kenya (Table 2).
Pooled prevalence of HBV among pregnant women in East Africa
As Fig 2 showed from a total of 45 studies, the overall pooled prevalence of HBV among pregnant women in East Africa was 6.0% (95% CI: 6% - 7%) with observed heterogeneity (I2 = 89.7%; p-value < 0.0001). The prevalence ranged from the lowest 1.5% reported from Somalia [56] to the highest prevalence of 22.2% reported from Ethiopia [9]. (Fig 2)
Source of heterogeneity and handling
Sub-group analysis.
Subgroup analysis was performed using the year of publication, sampling technique, and study design. (Table 3) Nine studies were published in the year 2020, twelve in 2021, fourteen in 2022, and ten in 2023, with the highest prevalence of 8% ((95% CI: 6%, 10%) I2 = 91.08%) seen in 2021 and the lowest prevalence 5% ((95% CI: 4%, 6%) I2 = 52.52%) observed in 2022. Here, the highest heterogeneity was observed in studies conducted in 2023 (I2 = 94.81%). (S1 Fig in S1 File)
Regarding study design, the highest prevalence 7% ((95% CI: 6%, 8%) I2 = 86.64%) was observed under cross-sectional study, and 4% ((95% CI: 3%, 6%) I2 = 94.04%) were under other studies. Based on study design highest heterogeneity (I2 = 94.04%) was observed studies conducted using other study designs (retrospective, prospective or cohort). (S2 Fig in S1 File)
On the other hand, 31 (68.89%) and 14 (31.11%) of the studies were conducted using probability sampling technique and non-probability sampling techniques respectively. Here the highest prevalence 7% (95% CI: 6%, 8%), I2 = 84.87%) was observed studies that were conducted using probability sampling techniques and 6% (95% CI: 4%, 7%), I2 = 90.33%) of prevalence was for studies conducted using non-probability sampling techniques. As results showed the highest heterogeneity was observed for studies that were conducted using the non-probability sampling technique. (S3 Fig in S1 File)
Sensitivity analysis
Sensitivity analysis was conducted, and the result showed that there is no single study whose value lies outside the 95% CI of the overall estimate or pooled prevalence.(Fig 3)
Publication bias
The Egger’s test and the funnel plot were conducted. The Egger’s test showed a statistical significant with p-value less than 0.05 and the funnel plot showed an asymmetry of the plot which were an indication of the presence of publication bias. (Fig 4)
This publication bias can be influenced by different factors such as journals may tend to publish studies that show significant results, editors and reviewers may have a bias towards accepting studies with positive results, researchers may manipulate data in order to determine significant findings and many more factors leading to publication bias.
As the asymmetry was detected using the funnel plot and Egger’s test; the trim-and-fill method (Fig 5) was used to re-estimate the pooled effect size by removing the outlying effect sizes, and then added back into the funnel plot and mirrored on the opposite side to identify the best estimate of the unbiased pooled effect size.
Pooled determinants of HBV among pregnant women
Here, studies that had two or more common risk factors were taken to identify the associated risk factors with HBV among pregnant women. Table 4 showed the pooled odds ratio of studies that had two and above risk factors in common and surgical procedure, history of having multiple sexual partners, history of body tattooing, history of tooth extraction, abortion history, history of sharing sharp material, blood transfusion, family history of HBV, and history of needle injury were significant risk factors associated with HBV among pregnant women.
A pooled meta-analysis showed that pregnant women who had a history of surgical procedures were 2.14 times more likely to be infected with HBV than who had not (OR = 2.14 (95% CI: 1.27, 3.61), I2 = 73.2%). Pregnant women who had multiple sexual partner had a 3.87 higher risk being HBV infection than pregnant women who had no multiple sexual partners (OR = 3.87(95% CI: 2.52, 5.95), I2 = 65.4%). Regarding the history of body tattooing, pregnant women who had a history of body tattooing were 2.55 times more likely to be infected than who had not (OR = 2.55 (95% CI: 1.62, 4.01), I2 = 75.9%). Similarly, pregnant women who had; history of tooth extraction/dental procedure (OR = 2.09 (95% CI: 1.29, 3.39), I2 = 66.9%), abortion history (OR = 2.20 (95% CI: 1.38, 3.50), I2 = 76.2%), history of sharing sharp material (OR = 1.88 (95% CI: 1.07, 3.31), I2 = 72.8%), blood transfusion (OR = 2.41 (95% CI: 1.62, 3.57), I2 = 58.0%), family history of HBV (OR = 4.87 (95% CI: 2.95, 8.05), I2 = 53.1%), and history needle injury (OR = 2.62 (95% CI: 1.20, 5.72), I2 = 67.8%) had higher risk of HBV infection than their counterparts.
Discussion
The prevalence of HBV is still high in eastern African countries [5] and HBV in pregnant women can transmit to unborn child during pregnancy [4]. Thus, determining the prevalence of HBV and its determinants among pregnant women improves knowledge, can be considered an input for concerned bodies, to develop prevention strategies and this study was aimed to determine the pooled prevalence and its determinants among pregnant women in East Africa.
Our systematic and meta-analysis used a total of forty five eligible studies with 35639 pregnant women and found that an overall/pooled prevalence of HBV among pregnant women in East Africa was 6.0% (95% CI: 6% - 7%). This finding is close to the study conducted in China, 6.64% [57] and in Nigeria, 6.49% [58]. On the other hand, the pooled prevalence was lower than a study conducted in Ghana, 13.1% [59], in Cammeron, 11.2% [60], and the prevalence was higher than a study conducted in Ethiopia, (4.75%) [7] and (4.7%) [8], in Iran, 1.2% [61]. This difference may be due to differences in participant characteristics, attention given by the government to the virus, study design, cultural and behavioral practices, geographical area, difference in publication year, and difference in applying sampling techniques.
This study identified history of surgical procedure, history of having multiple sexual partners, history of body tattooing, history of tooth extraction, history of sharing sharp materials, history of abortion, blood transfusion, and family history of HBV were among the risk factors of pregnant women for HBV. Pregnant women who had history of surgical procedure had higher risk of acquiring HBV infection than their counterparts. This may be due to weakened immune systems, the use of medical instruments and equipment that are not properly sterilized. This finding is supported by a study [3, 26].
HBV infection transmission increases during sexual activity and the number of sexual partners exposed [1]. Our study showed pregnant women having multiple sexual partners were at higher risk as compared to pregnant women who didn’t have multiple sexual partner. This may be due to the fact that they have had more opportunities to come into contact with the virus through unprotected sex, and the more sexual partners a person has, the higher their risk of exposure to HBV. This finding is in line with studies conducted by [3, 26, 62, 63]. The pregnant women with body tattoo were more likely to be infected with HBV. This is may be due to the possibility for exposure to contaminated needles and unsterilized equipment during the tattooing process. The result is agreed with [7, 13, 64].
Furthermore, the present study found that pregnant women who had a history of tooth extraction were at higher risk of HBV infection. This could be due to bleeding during tooth extraction, which increases the risk of blood exposure, dental instruments not properly sterilized; and dental professionals not following proper infection control procedures. The finding supported by [65]. In addition, pregnant women with an abortion history were more likely to be infected with HBV. The possible reason may be pregnant women who had history of previous abortion may had contact with healthcare facilities that were not properly sterilized, which increases the risk of exposure to communicable diseases. The result agreed with [3, 13, 62].
Pregnant women who had a history of sharing sharp material were at higher risk as compared with those pregnant women who had no history of sharing sharp materials. The possible explanation might be that sharing sharp materials increases the likelihood of exposure to infected blood or body fluids, which can lead to direct contact with infected fluids. This result was consistent with a study conducted in Jigjiga, Ethiopia [26].
The odds of having a history HBV infection among pregnant women who had a history of blood transfusion were higher than those of pregnant women who didn’t have history of blood transfusion. The possible explanation may be the possible explanations may be HBV remains a major risk of transfusion-transmitted infection due to the pre-seroconversion window period, infection with immunovariant viruses, and with occult carriage of HBV infection[66]. This is consistent with a study conducted in Kenya [67], Ethiopia [68, 69]. In addition, pregnant women who had a family history of HBV infection were more likely to be at risk as compared to pregnant women who had no family history of HBV infection. The possible explanation for this may be that pregnant women may have been exposed to the virus at a younger age through close contact with infected family members and genetic factors may play a role in susceptibility to HBV infection. This finding is consistent with a study conducted in Jigjiga, Ethiopia [26].
This study has its own strengths and weaknesses. It is the first study to determine the pooled prevalence of HBV infection among pregnant women in East Africa, which provides a more precise estimate of the overall effect size by integrating data from multiple studies. Among the limitations of this study; firstly, studies written other than in English were ignored, so studies conducted in other languages were missed. Secondly, high heterogeneity was observed. This was an indication that the effect size was different across studies due to study design, geographical region, population, and study year. A random effect model (DerSimonian) and subgroup analysis were conducted to overcome this problem. Thirdly, publication bias was observed due to the researchers of individual studies manipulating data in order to determine significant findings. We used the trim and fill plot procedure to identify the best estimate of the unbiased pooled effect size.
Conclusion and recommendation
The pooled prevalence of HBV infection among pregnant women in East Africa was an intermediate level and different across countries ranging from 1.5% to 22.2%. History of surgical procedure, history of having multiple sexual partners, history of body tattooing, history of tooth extraction, history of sharing sharp materials, history of abortion, blood transfusion, and family history of HBV were the risk factors responsible for this intermediate level of prevalence among pregnant women in East Africa. The result of this prevalence was an indication of the need for screening, prevention, and control of HBV infection among pregnant women in the region. Therefore, early identification of risk factors, awareness creation on the mode of transmission HBV and implementation of preventive measures are essential in reducing the burden of HBV infection among pregnant women.
Acknowledgments
The authors of the primary studies that were included in this review were acknowledged.
References
- 1. Umer A., et al., Prevalence of hepatitis B infection and its associated factors among pregnant mothers attending antenatal care at public hospitals at Hararghe, Eastern Ethiopia. Frontiers in Global Women’s Health, 2023. 4: p. 1056488. pmid:37181544
- 2. Kampe A., et al., Seroprevalence of Hepatitis B Virus Infection and Associated Factors Among Pregnant Women Attending Antenatal Care At Public Hospitals in Borena Zone, Southern Ethiopia. Health Services Research and Managerial Epidemiology, 2023. 10: p. 23333928231161946. pmid:36970374
- 3. Umare A., et al., Hepatitis B Virus Infections and Associated Factors among Pregnant Women Attending Antenatal Care Clinic at Deder Hospital, Eastern Ethiopia. PLoS One, 2016. 11(11): p. e0166936. pmid:27898721
- 4.
Global Hepatitis Report. 2017, Geneva: World Health Organization.
- 5. Kafeero H.M., et al., Prevalence and predictors of hepatitis B virus (HBV) infection in east Africa: evidence from a systematic review and meta-analysis of epidemiological studies published from 2005 to 2020. Arch Public Health, 2021. 79(1): p. 167. pmid:34537079
- 6. Al-Mamari* A., Determine seroprevalence and associated risk factors of HBV infection among pregnant women and it relationship with blood transfusion at Hargeisa Group Hospital, Hargeisa, Somaliland. International Journal of Clinical Virology, 2019: p. 001–009.
- 7. Alemu A.A., et al., Hepatitis B Virus Infection and Its Determinants among Pregnant Women in Ethiopia: A Systematic Review and Meta-Analysis. Infect Dis Obstet Gynecol, 2020. 2020: p. 9418475. pmid:32577077
- 8. Kebede K.M., Abateneh D.D., and Belay A.S., Hepatitis B virus infection among pregnant women in Ethiopia: a systematic review and Meta-analysis of prevalence studies. BMC Infect Dis, 2018. 18(1): p. 322. pmid:29996785
- 9. Kassaw M.A., Amera E.D., and Azanaw K.A., Magnitude and Associated Risk Factor of HBV Virus Among Pregnant Mothers Attending Antenatal Care in Debre Tabor Referral Hospital; Northwest Ethiopia. 2021.
- 10. Kiros K.G., et al., Seroprevalence of hepatitis B virus infection, mother-to-child transmission, and associated risk factors among delivering mothers in Tigray Region, Northern Ethiopia: a cross-sectional study. Infectious Diseases and Therapy, 2020. 9: p. 901–911.
- 11. Geda Y.F., et al., Hepatitis B surface antigen and associated factors among mothers who had antenatal care contact in Attat Hospital, southern Ethiopia. SAGE Open Medicine, 2021. 9: p. 20503121211024462. pmid:34178340
- 12. Gebretsadik D., et al., High seroprevalence of hepatitis B and C virus infections among pregnant women attending antenatal clinic in Borumeda General Hospital, northeast Ethiopia. BioMed Research International, 2022. 2022. pmid:36072475
- 13. Kinfe H., Sendo E.G., and Gebremedhin K.B., Prevalence of hepatitis B virus infection and factors associated with hepatitis B virus infection among pregnant women presented to antenatal care clinics at Adigrat General Hospital in Northern Ethiopia. International Journal of Women’s Health, 2021: p. 119–127. pmid:33519245
- 14. Nour H. and Ali I., Sero-Prevalence of Hepatitis B Virus Infection and Associated Factors among Pregnant Women Attending Antenatal Care at Edna Adan University Hospital Hargeisa, Somaliland, 2022-A Cross-Sectional Study. Int J Womens Health Wellness, 2022. 8(140): p. 2474–1353.
- 15. Wakjira M., et al., Prevalence of hepatitis B virus and its associated factors among pregnant women attending antenatal care in Ambo town, Central Ethiopia: A cross-sectional study. Clinical Epidemiology and Global Health, 2022. 15: p. 101054.
- 16. Tadiwos M.B., et al., Sero-prevalence of hepatitis B virus infection and associated factors among pregnant women attending antenatal care services in Gedeo Zone, Southern Ethiopia. Journal of Primary Care & Community Health, 2021. 12: p. 2150132721993628. pmid:33565356
- 17. Dirir S.D., et al., Seroprevalence of Hepatitis B Virus Infection and Associated Factors among Pregnant Women Attending Antenatal Care centers in Djbouti City, Republic of Djibouti. Archives of Clinical and Medical Case Reports, 2023. 7(4): p. 304–312.
- 18. Bafa T.A. and Egata A.D., Seroepidemiological patterns and predictors of hepatitis B, C and HIV viruses among pregnant women attending antenatal care clinic of Atat Hospital, Southern Ethiopia. SAGE Open Medicine, 2020. 8: p. 2050312119900870. pmid:32002184
- 19. Mamuye B., Gobena T., and Oljira L., Hepatitis B virus infection and associated factors among pregnant women attending antenatal clinics in West Hararghe public hospitals, Oromia region, Ethiopia. The Pan African Medical Journal, 2020. 35.
- 20. Workye H., et al., Prevalence and Associated Factors of Hepatitis B Virus Infection among Pregnant Women Attending Antenatal Care in Agena Health Center, South Ethiopia: A Cross-Sectional Study. J Clin Cell Immunol, 2022. 13: p. 674.
- 21. Firde M., et al., Sero-prevalence and Risk Factors Associated with Hepatitis B Virus Infections among Pregnant Women at Shone Hospital, Southern Ethiopia: A Cross-sectional Study. Journal of Midwifery & Reproductive Health, 2022. 10(1).
- 22. Machar M.P. and Jara D., Seroprevalence and associated risk factors for Hepatitis B Virus infections among apparently healthy pregnant mothers attending Anc in Rubkona primary health care center in Rubkona County, Unity State, South Sudan. Archives of Hepatitis Research, 2021. 7(1): p. 004–013.
- 23. Mosa B.D., et al., Sero-Prevalence and Associated Factors of Hepatitis B Virus Among Pregnant Women at Wolkite Health Center. Archives of Microbiology and Infectious Diseases, 2022. 1(1): p. 1–6.
- 24. Bancha B., et al., Prevalence of hepatitis B viruses and associated factors among pregnant women attending antenatal clinics in public hospitals of Wolaita Zone, South Ethiopia. PloS one, 2020. 15(5): p. e0232653. pmid:32379803
- 25. Tesfu M.A., Habtemariam T.T., and Belay N.B., Risk factors associated with Hepatitis B virus infection among pregnant women attending public hospitals in Addis Ababa, Ethiopia. Plos one, 2023. 18(4): p. e0284646. pmid:37099607
- 26. Roble A.K., et al., Seroprevalence of hepatitis B virus and associated factors among pregnant women attending antenatal care in public health facilities in Jigjiga Town, Eastern Ethiopia. International Journal of Women’s Health, 2021: p. 1299–1310. pmid:33447090
- 27. Atalay A.A., et al., Seroprevalence of hepatitis B virus among pregnant women attending Antenatal care in Dilla University Referral Hospital Gedio Zone, Ethiopia; health facility based cross-sectional study. Plos one, 2021. 16(3): p. e0249216. pmid:33765065
- 28. Kenea D. and Lemessa F., Assessment of hepatitis B virus infection and associated factors among pregnant women attending antenatal care service in Bishoftu Town, South East, Ethiopia. American Journal of Health Research, 2020. 8(2): p. 11–17.
- 29. Dagnew M. and Million Y., Hepatitis B and C Viruses’ Infection and Associated Factors among Pregnant Women Attending Antenatal Care in Hospitals in the Amhara National Regional State, Ethiopia. 2020. 2020: p. 8848561. pmid:33133191
- 30. Marama T., et al., Burden of hepatitis B surface antigen sero-prevalence and associated factors among pregnant women receiving antenatal care at a public health institution, southern Ethiopia, 2018: implications for public health prevention. 2018. 36(4): p. 290–297.
- 31. Kassaw B., et al., Sero-prevalence and associated factors of hepatitis B virus among pregnant women in Hawassa city public hospitals, Southern Ethiopia: Cross-sectional study design. SAGE Open Medicine, 2022. 10: p. 20503121221140778. pmid:36505974
- 32.
Angom D.B., Prevalence And Risk Factors Of Hepatitis B Virus Infection Among Pregnant Women Attending Antenatal Clinic At Lira Regional Referral Hospital. 2021, Clarke International University.
- 33. Shedura V.J., Mchau G.J., and Kamori D., High seroprevalence and associated risk factors for hepatitis B virus infection among pregnant women living with HIV in Mtwara region, Tanzania. Bulletin of the National Research Centre, 2023. 47(1): p. 43.
- 34.
Ahmed Mohamud S., Prevalence and associated factors for hepatitis B virus infection among pregnant women in Banadir hospital, Mogadishu, Somalia. 2023, Makerere University.
- 35. Assefa A., Kiros T., and Delelegn B., Seroprevalence and Associated Factors of HBV and HCV among Pregnant Women Attending Antenatal Care at Debre Tabor Comprehensive Specialized Hospital, Northwest Ethiopia: A Cross-Sectional Study. International Journal of Microbiology, 2023. 2023. pmid:37576850
- 36.
Bogale M. and Balta B., Sero-prevalence of hepatitis b virus and associated factors among pregnant women’s attending antenatal clinics in public hospitals of Hawassa City, Sidama, Ethiopia, 2021. Multicenter cross sectional study. 2021.
- 37. Argaw B., et al., Sero-Prevalence, Infectivity, and Associated Risk Factors of Hepatitis B Virus Among Pregnant Women Attending Antenatal Care in Sankura Primary Hospital, Silte Zone, Southern Ethiopia, 2021. The Open Microbiology Journal, 2022. 16(1).
- 38. Kayondo S.P., Byamugisha J.K., and Ntuyo P., Prevalence of hepatitis B virus infection and associated risk factors among pregnant women attending antenatal clinic in Mulago Hospital, Uganda: a cross-sectional study. BMJ open, 2020. 10(6): p. e033043. pmid:32499255
- 39. Tadesse M., et al., Assessment of prevalence of Hepatitis B virus and its associated factors among pregnant women from Wolaita Sodo, Ethiopia. Journal of Clinical Virology Plus, 2022. 2(2): p. 100069.
- 40. Mugabiirwe N., et al., Hepatitis B virus infection and HBeAg positivity among pregnant women in South West Uganda. African Journal of Laboratory Medicine, 2022. 11(1): p. 1–6. pmid:36091351
- 41. Jok T.A. and Ninancherian S., Hepatitis B chronic infection among pregnant women attending the antenatal care in Bor State Referral Hospital, South Sudan. 2023.
- 42. Modesti P., Reboldi G., and Cappuccio F.J.P.O., Newcastle-Ottawa Quality Assessment Scale (adapted for cross sectional studies). 2016. 11(1): p. e0147601.
- 43. Higgins J.P., et al., Measuring inconsistency in meta-analyses. 2003. 327(7414): p. 557–560. pmid:12958120
- 44. Egger M., et al., Bias in meta-analysis detected by a simple, graphical test. 1997. 315(7109): p. 629–634. pmid:9310563
- 45. Dowdy A., et al., Meta-analytic methods to detect publication bias in behavior science research. 2022. 45(1): p. 37–52. pmid:35342865
- 46. Page M.J., et al., The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. 2021. 372.
- 47. Geffert K., et al., Prevalence of chronic HBV infection in pregnant woman attending antenatal care in a tertiary hospital in Mwanza, Tanzania: a cross-sectional study. BMC infectious diseases, 2020. 20(1): p. 1–10.
- 48. Demeke G. and Ayalneh G.M., Sero-Prevalence and Associated Factors of Hepatitis B Virus Among Pregnant Women at North West Ethiopia: An Institution-Based Cross-Sectional Study. 2021. 14: p. 2799–2805. pmid:34194239
- 49. al A.e., Seroprevalence of Hepatitis B Virus and Associated Factors among Pregnant Women Attending Antenatal Care Services at Public Health Facilities in Nekemte Town. Int J Gen Med, 2021. 2021: p. 9572235.
- 50. Loarec A., et al., Prevention of mother-to-child transmission of hepatitis B virus in antenatal care and maternity services, Mozambique. Bulletin of the World Health Organization, 2021. 100(1): p. 60.
- 51. Eba S., Prevalence of hepatitis B infection and its associated factors among pregnant mothers attending antenatal care at public hospitals at Hararghe, Eastern Ethiopia. Int J Reprod Med, 2021. 4: p. 1056488.
- 52. Genetu K. and Abere K., Magnitudes and Correlates of Human Immunodeficiency Virus, Hepatitis B Virus, and Syphilis among Pregnant Mothers Attending Antenatal Care in Addis Ababa, Ethiopia. 2022. 2022: p. 6156613. pmid:35221648
- 53. Kumalo A. and Teklu T., Undiagnosed Seroprevalence of Hepatitis B and C Virus Infections in the Community of Wolaita Zone, Southern Ethiopia. 2022. 14: p. 111–122. pmid:35971532
- 54.
Malungu J.A., Prevalence of Hepatitis B Virus, Social Demographic Factors and Circulating Genotypes among Antenatal Clinic Attendees at Mbagathi Country Referral Hospital. 2022, JKUAT-COHES.
- 55. Duri K., et al., Antenatal hepatitis B virus sero-prevalence, risk factors, pregnancy outcomes and vertical transmission rate within 24 months after birth in a high HIV prevalence setting. BMC Infectious Diseases, 2023. 23(1): p. 736.
- 56. Luqmaan F.M., et al., Seroprevalence of Hepatitis B Virus Infection and Associated Factors Among Antenatal Clinic Attendees at SOS Hospital, Mogadishu, Somalia. African Journal of Health and Medical Sciences (AFJHMS), 2023. 8: p. 14–25.
- 57. Liu D., et al., Hepatitis B Infection Among Pregnant Women in China: A Systematic Review and Meta-Analysis. Front Public Health, 2022. 10: p. 879289. pmid:35493378
- 58. Olakunde B.O., et al., A systematic review and meta-analysis of the prevalence of hepatitis B virus infection among pregnant women in Nigeria. PLoS One, 2021. 16(10): p. e0259218. pmid:34714888
- 59. Ofori-Asenso R. and Agyeman A.A., Hepatitis B in Ghana: a systematic review & meta-analysis of prevalence studies (1995–2015). BMC Infect Dis, 2016. 16: p. 130.
- 60. Bigna J.J., et al., Seroprevalence of hepatitis B virus infection in Cameroon: a systematic review and meta-analysis. BMJ Open, 2017. 7(6): p. e015298. pmid:28667212
- 61. Moghaddasifar I., et al., Prevalence of Hepatitis B Virus infection among Pregnant Women in Iran: A Systematic Review and Meta-analysis. Iranian Journal of Cancer Prevention, 2016. In Press(In Press).
- 62. Tanga A.T., et al., Sero-prevalence of hepatitis B virus and associated factors among pregnant women in Gambella hospital, South Western Ethiopia: facility based cross-sectional study. BMC Infect Dis, 2019. 19(1): p. 602. pmid:31291901
- 63. Hillary A., et al., Prevalence and factors associated with hepatitis B surface antigen positivity among women receiving antenatal care at Mbarara Regional Referral Hospital. 2019.
- 64. Desalegn Z., et al., Hepatitis B and human immunodeficiency virus co-infection among pregnant women in resource-limited high endemic setting, Addis Ababa, Ethiopia: implications for prevention and control measures. Eur J Med Res, 2016. 21: p. 16. pmid:27075475
- 65. Molla S., Munshea A., and Nibret E., Seroprevalence of hepatitis B surface antigen and anti HCV antibody and its associated risk factors among pregnant women attending maternity ward of Felege Hiwot Referral Hospital, northwest Ethiopia: a cross-sectional study. Virol J, 2015. 12: p. 204. pmid:26626263
- 66. Candotti D. and Allain J.-P.J.J.o.h, Transfusion-transmitted hepatitis B virus infection. 2009. 51(4): p. 798–809. pmid:19615780
- 67. Gatheru Z., et al., Factors Associated with Hepatitis B Surface Antigen Seroprevalence amongst Pregnant Women in Kenya. Open Journal of Obstetrics and Gynecology, 2018. 08(05): p. 456–467.
- 68. Gedefaw G., et al., Risk factors associated with hepatitis B virus infection among pregnant women attending antenatal clinic at Felegehiwot referral hospital, Northwest Ethiopia, 2018: an institution based cross sectional study. BMC Res Notes, 2019. 12(1): p. 509. pmid:31416477
- 69. Mekonnen R., Admasu D., and Belete M., Sero-Prevalence of Hepatitis B Virus and Associated Factors Among Pregnant Mothers Attending Antenatal Care in Public Health Facilities, Dire Dawa. Journal of Medical Microbiology & Diagnosis, 2018. 07(03).