Results of Intervention to Prevent Mother-to-Child Transmission of HBV Using Health Education for Mothers and Children at Hai Phong Obstetrics and Gynecology Hospital

of the World Health Organization to prevent mother-to-child transmission of HBV [146].

Although high maternal HBV-DNA levels are one of the high risk factors for mother-to-child HBV transmission, if these mothers participate in prophylactic treatment for mother-to-child transmission in the second or third trimester, the effectiveness of measures to prevent mother-to-child HBV transmission will be increased. Our results show that children born to mothers who were prescribed treatment but did not participate in treatment had a 24.4-fold higher risk of being HBsAg positive than children born to mothers who participated in treatment when prescribed (OR=24.4; 95%CI: 2.0-296.2; p < 0.05) and there was no statistically significant difference between children born to mothers who participated in treatment when prescribed and mothers who did not have treatment indications with p > 0.05 (Table 3.15). Our study results are similar to the study results of author Yi P in 2018, the HBV transmission rate in the group of children born to mothers participating in tenofovir treatment (2.0%) was lower than that of the control group at 20.0% [168].

Children born to mothers with HBeAg positivity had a 31.3 times higher risk of being HBsAg positive than children born to mothers with HBeAg positivity (OR=31.3; 95%CI: 6.4- 154.1; p < 0.001) (Table 3.16). Our study results are similar to the study results of author Phi Duc Long, the rate of HBsAg carriage in children is higher when the mother is positive for both HBsAg and HBeAg [154]. Some other studies also showed that the rate of failure of passive-active immunity in children born to mothers with HBeAg positivity reached 8-32% [60], [64], [166].

Among 35 mothers with HBeAg positive, children born to mothers not receiving anti-HBV treatment had a 31.3 times higher risk of being HBsAg (+) than those born to mothers receiving anti-HBV treatment (OR: 31.3; 95%CI: 2.9 - 341.8; p < 0.05) (Table 3.17). Our study results are similar to the study results of author Burgis on 17,687 children born to mothers positive for

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HBsAg in California from January 1, 2005 to December 31, 2011 recommended that pregnant women with HBeAg (+) should be considered for treatment even with low HBV-DNA levels to control the risk of mother-to-child HBV transmission [65]. Most current guidelines focus on HBV-DNA levels to make recommendations for treatment to prevent mother-to-child HBV transmission, and maternal HBeAg status is only recommended as a criterion for treatment of chronic HBV infection if there is an ALT level that is twice the upper limit of normal and a high HBV-DNA level above 20,000 IU/ml (10 5 copies/ml) [144]. However, previous studies have also shown that maternal HBeAg positivity is an independent risk factor for mother-to-child HBV transmission [158], [159], [160], [165]. From there, we realized that there is a need for more in-depth studies on mother-to-child HBV transmission in the group of mothers carrying HBeAg, from which there are different intervention plans for mothers with HBeAg (+) to minimize the possibility of vertical transmission from mother to child even when the pregnant woman has normal ALT levels.

Evaluating the relationship between the mother's HBV-DNA concentration at birth and the HBsAg (+) carrier status in 12-month-old children, the results in Table 3.18 show that the rate of HBsAg (+) carrier status in the group of children born to mothers with high HBV-DNA concentration above 200,000 IU/ml is higher than that of the group of mothers with HBV-DNA concentration <

200,000 IU/ml, however, the difference was not statistically significant with p > 0.05. The reason why our study did not find a significant relationship between these two factors is because our study was a longitudinal study, mothers with HBV-DNA levels > 200,000 IU/ml at 7 months were counseled and participated in treatment to prevent mother-to-child HBV transmission. Therefore, although the results obtained were higher transmission rates in the high-risk group of mothers (HBV levels

– DNA > 200,000 IU/ml) but no correlation has been shown from this result.

In the multivariate regression model of factors associated with mother-to-child HBV transmission at 12 months of age, maternal HBeAg status was the only independent predictor of perinatal HBV transmission (OR=65.8; 95%CI: 7.3- 594.1; p<0.001) (Table 3.19).

Thus, from the results of the longitudinal follow-up process from the first month of pregnancy when the mother was screened for HBsAg (+) to the 12-month-old child, with the practical application of recommended transmission prevention measures, the rate of HBV transmission from mother to child was 8.0%. The factor that really affects perinatal HBV transmission is the mother's HBeAg status. The results of our study have provided further evidence that the presence of HBeAg in the blood of mothers increases the risk of vertical HBV transmission to their children. This suggests that the authors can conduct more extensive studies on the influence of HBeAg on vertical transmission to have enough evidence for recommendations in the prevention of HBV transmission from mother to child towards the goal of eliminating hepatitis B virus.

4.2. Results of intervention to prevent HBV transmission from mother to child through health education communication for mothers and health workers at Hai Phong Obstetrics and Gynecology Hospital

From the results of the assessment of the current situation and transmission rate, we found that the rate of HBsAg carriage in pregnant women in our study is still high (10.6%) and there is still a long way to go to achieve the WHO's global strategic goal of reducing the incidence rate by 90% by 2030, equivalent to 0.1% of the HBsAg prevalence rate in children. Although Vietnam has a "National Action Plan on Eliminating Mother-to-Child Transmission of HIV, HBV and Syphilis for the 2018-2030 period", the new guidelines only apply to HBV examination and testing during pregnancy as a routine test, but there are no specific professional guidelines on monitoring and management.

Management of pregnant women with HBsAg and children born to these mothers for obstetrical health workers.

In the WHO Report on “Progress on Control of HBV and Elimination of Mother-to-Child Transmission of HBV in the Western Pacific Region 2005-2017” released on March 1, 2019, it was reported that the coverage of the first dose of HBV vaccine for newborns increased from 63% to 85% during the period 2005-2017. The coverage of the third dose of HBV vaccine as recommended increased from 76% to 93% during the same period. Globally, the coverage of the first and third doses of HBV vaccine in 2017 was 43% and 84%, respectively. In another report on “Impressive Progress with Young Children” at the same time, it was recommended that “In addition to preventing 7 million deaths with HBV vaccines, promoting HBV elimination in the region by 2030 requires an equally ambitious program to reach mothers”. Therefore, improving maternal awareness of healthcare is also necessary to limit the rate of chronic HBV infection towards achieving the WHO target.

From that, we realized that implementing health education communication on 2 groups of mothers and health workers to improve knowledge, attitudes, and practices of subjects on preventing HBV transmission from mother to child has certain significance to increase the effectiveness of recommended preventive measures.

4.2.1. Results of communication intervention on mothers

Along with guidelines for preventing mother-to-child transmission of HBV, such as antiviral therapy, postnatal HBV vaccination, and serological testing, maternal health education is a low-cost but effective measure to eliminate new infections in children under 5 years of age.

At the time pregnant women were confirmed to be chronic HBV carriers and agreed to participate in a longitudinal study to assess the rate of mother-to-child transmission of HBV, we conducted a baseline assessment of knowledge and attitudes toward HBV.

VGB levels of 183 mothers and implemented a health education communication intervention to change their knowledge, attitudes, and practices (KAP) on this issue. Post-intervention assessment was conducted at 6 months postpartum on 176 mothers who were followed. Therefore, the sample size for us to compare before and after the intervention in the study evaluating the results of the health education communication intervention for mothers was 176. Regarding the characteristics of the group of mothers participating in the intervention study, the average age was 30 years old, most of them had graduated from high school and were working with a stable income (average 5-10 million VND/month).

The questionnaire to initially assess knowledge and attitudes of pregnant women in the 7th month includes 17 questions on: Epidemiology of HBV (incidence, consequences, transmission routes and measures to prevent HBV infection); Measures to prevent HBV transmission from mother to child; Mothers' attitudes towards prevention of HBV transmission. The results of our study show that mothers still lack knowledge about HBV and HBV transmission from mother to child. This leads to a significant proportion of mothers still having negative attitudes towards measures to prevent HBV transmission.

After initially assessing the knowledge and attitudes of pregnant women, we directly counseled each pregnant woman on the transmission routes, consequences, and measures to prevent HBV transmission from mother to child in HBsAg-positive mothers and instructed these mothers on the plan for managing the next stage of pregnancy and how to care for the child after birth. At 6 months after birth, we re-evaluated after the intervention. The post-intervention assessment questionnaire consisted of 21 questions, including 17 questions assessing the knowledge and attitudes of mothers as in the initial assessment, and 5 additional questions assessing the practices of mothers in participating in prescribed treatment; injecting the newborn dose of HBV vaccine; injecting HBIG and injecting the next doses of vaccine in the immunization program. The results showed that after the intervention, most of the indicators of knowledge and attitudes of pregnant women were improved.

All mothers had positive changes, the rate of practice achievement after intervention was at a high level.

quite high

Knowledge intervention results:

From the initial knowledge assessment results, we found that most pregnant women lacked knowledge about the incidence and consequences of chronic HBV (the correct knowledge rates were 28.4% and 36.4%, respectively) (Table 3.20). Our study results were similar to the correct knowledge rate of pregnant women in the Northern region of Vietnam in the study by author Pham Thi Thanh Hang in 2019: only 25.8% of pregnant women were correctly aware of the incidence of HBV in Vietnam. Although the correct answer rate about the incidence and consequences of chronic HBV increased significantly after the intervention, it was only achieved by about 51% of mothers (50.6% and 47.7%; p < 0.001).

The majority of mothers participating in our study had correct knowledge about HBV transmission routes through unprotected sex with an HBV-infected person (83.5%), through blood (86.4%), and from mother to child (85.2%) (Table 3.24). The rate of pregnant women with correct knowledge about HBV transmission routes in our study was similar to the rate in the study by author Pham Thi Thanh Hang in 2017, which was more than 85.8% [11]; and higher than the rate in the study by author Zhenyan Han in 2017, where only about 50% of pregnant women knew that HBV could be transmitted through unsafe sex and 20% did not know that they could transmit HBV to their children [176]. After the intervention, the rate of correct knowledge about prevention of HBV transmission from mother to child increased significantly with p < 0.05 (Table 3.21). 100% of mothers in our study knew that HBV can be transmitted from mother to child. This shows that providing information about HBV to pregnant women is initially meaningful in improving awareness of HBV in this group, from which it can be expected that they will have a positive attitude and practice correctly in preventing HBV transmission from mother to child.

When asked about measures to prevent HBV infection, most mothers knew that vaccination, not sharing needles and using condoms during sex were effective measures (rates were 90.9%; 90.4% and 88.6%, respectively). After the intervention, the percentage of correct knowledge of mothers increased, with a difference of 0.6 to 9.1% (Table 3.21). The results of our study are similar to the results of the study by author Chan in China in 2010 [94] and by author Pham Thi Thanh Hang in the Northern region of Vietnam in 2019 [11], most pregnant women had correct knowledge about measures to prevent HBV infection, however, in all 3 studies, the lowest percentage of correct knowledge was using condoms during sex. This is also a point to note for future reproductive health education programs because sexual transmission is a recognized and common method of transmission in many countries around the world.

The results of the intervention on knowledge about measures to prevent HBV transmission from mother to child are shown in Table 3.22. After the intervention, the proportion of pregnant women with correct knowledge increased significantly with p < 0.05; in which 100% of pregnant women knew that it was necessary to test for HBV during pregnancy and vaccinate their children against HBV according to the vaccination program. Although the mothers in our study were all provided with information about the first dose of HBV vaccine, after the intervention, the proportion of mothers who answered correctly about the timing of HBV vaccination within 24 hours after birth was 86.4%. This predicts a risk of not providing the first dose of vaccine to children in time due to this lack of knowledge. A study by author Nguyen Tran Hien in 2014 showed that the prevalence of HBsAg in children vaccinated with the first dose of VGB vaccine after 7 days was significantly higher (3.20%) than those vaccinated 0 to 1 day after birth (1.52%) (PR: 2.09, CI: 1.27–3.46) [108].

Attitudinal intervention results:

After the intervention, the proportion of mothers with positive attitudes towards measures to prevent mother-to-child transmission of HBV increased significantly with p < 0.05 (Table 3.23). 100%

Mothers who are concerned about HBV infection during pregnancy, believe in the effectiveness of HBV vaccine in preventing HBV infection and the safety of the newborn dose of HBV vaccine, answered that they would vaccinate their child with HBV vaccine within 24 hours after birth if the child is healthy and stable; willing to vaccinate if the doctor says that HBV vaccine is safe for newborns. The rate of mothers who believe in the effectiveness and safety of HBV vaccine in our study is higher than that of author Tran Xuan Bach in a study assessing the impact of the media on beliefs and behaviors related to vaccines and side effects of vaccines at a vaccination clinic in central Hanoi, Vietnam in 2018, nearly 3/4 of mothers were hesitant about vaccines because they had heard about side effects after vaccination in the media [173]. However, after the intervention, only half of the mothers felt comfortable using medication during pregnancy, this rate poses a major challenge in preventing HBV transmission in pregnant women with high HBV-DNA levels. Our results are similar to the results of author Degli Esposti in 2011, most pregnant women feel concerned when being advised to use medication during pregnancy [177].

The results of Table 3.24 show that the percentage of good knowledge and positive attitudes of mothers both increased significantly after the intervention. The effectiveness index after the intervention reached 25.5% for knowledge and 40.7% for attitude, p < 0.05. From the results of the study, we found that when mothers are provided with enough information, it will help mothers have a more positive attitude towards measures to prevent HBV transmission from mother to child.

We found that the intervention using health education communication helped improve the average score of mothers' knowledge and attitudes about VGB disease. After the intervention, the average knowledge score increased by 1.38 points, the effectiveness index was 15.9%; the average attitude score increased by 0.87 points, the effectiveness index was 27.0%. The change was statistically significant with p < 0.001 (Table 3.25). The results of our study are similar to other studies, health education communication for

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