Hepatitis C infection is an emerging worldwide public health concern affecting millions of people each year [
According to World Health Organization (WHO) global health impact report of viral hepatitis, about 130 to 150 million people were affected by chronic HCV infection globally, reaching endemic proportions in sub-Saharan Africa (SSA). It is also estimated to result in 350,000 to 500,000 deaths annually [
The prevalence of maternal HCV infection during pregnancy ranged from 1 to 8% worldwide [
Maternal HCV infection during pregnancy is associated with a high risk of maternal complications including preterm delivery, placental separation, vaginal bleeding, premature rupture of membranes, and mortality [
In the health system of Ethiopia, the health burden due to viral hepatitis, in general, is still given less [
In the control of vertical transmission of HCV disease, estimating its prevalence among pregnant women is very important. There are variable reports on the prevalence of HCV infection among pregnant women in Ethiopia; however, the variations have not been examined systematically. Moreover, there was not a nationwide study assessing the pooled prevalence of HCV infection among pregnant women. This study aims to estimate the pooled prevalence of HCV infection among pregnant women based on the available studies using systematic review and meta-analysis methods. The findings of this meta-analysis will help policymakers and other concerned bodies to provide a quantified estimate of the problem as a step toward a better understanding of the HCV epidemiology, identify gaps in HCV screening during ANC, and plan strategies to increase awareness of the general population and healthcare workers regarding the epidemiology of HCV.
A systematic review and meta-analysis was conducted to estimate the prevalence of HCV during pregnancy in Ethiopia. This review was conducted in Ethiopia which is found in the Horn of Africa. The country covers an area of 1, 100,000 km2 and divided into 9 regions, namely, Tigray, Afar, Amhara, Oromia, Somali, Benishangul-Gumuz, Southern Nations Nationalities and People Region (SNNPR), Gambella, Harari, and two Administrative states (Addis Ababa city administration and Dire Dawa city administration). Currently, the population of Ethiopia is estimated to be more than 112 million [
The search was focused on the prevalence of HCV during pregnancy in Ethiopia and carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [
During the advanced search, articles/documents were downloaded into Endnote software version 7 × 2.1 to manage references. After excluding duplicates, titles and abstracts and full texts of the remained papers were screened to determine the relevance of the studies. The PRISMA flow diagram was used to summarize the study selection processes [
Study area: only studies conducted in Ethiopia were included
Design: all observational studies reporting the prevalence of HCV among pregnant women in Ethiopia were included
Publication status: both published and unpublished articles were considered
Language: the articles published only in the English language were included
Publication year: all publications irrespective of publication or reporting year were considered (the published time was from 2014 to 2019)
Before exclusion, the titles, abstracts, and full texts of the studies were cautiously reviewed for eligibility. Articles that did not clearly report the prevalence of HCV among pregnant women in Ethiopia were excluded. In addition, articles published in languages other than English and outside Ethiopia were excluded. Review, case reports, editorials or commentaries, and case studies were also excluded.
Data were extracted using a standardized data extraction tool adapted from Joanna Briggs Institute (JBI) Meta-Analysis of Statistics Assessment and Review Instruments [
The overall quality of all included studies was assessed using a critical appraisal checklist for observational studies adopted from JBI [
The main outcome required for the final meta-analysis was the “prevalence of HCV among pregnant women in Ethiopia.” The prevalence was calculated by dividing the number of pregnant women with confirmed HCV infection by the total number of pregnant women who have been included in the study (sample size) multiplied by 100.
Data were analyzed using statistical software STATA version 11. To summarize the selected studies, tables and figures were used. The overall pooled prevalence of HCV among pregnant women was estimated using a random-effects meta-analysis. A random-effects meta-analysis model was used to minimize the random variations between the point estimates of the primary studies since heterogeneity was exhibited. Point prevalence as well as their 95% confidence intervals (CI) was exemplified by forest plots. The degree of heterogeneity among the results of the selected studies was detected using the Cochrane test (
In the search of the literature, 502 potential studies were identified. Of these, 104 were duplicates and were removed. After screening the titles and abstracts, 347 irrelevant studies were excluded from the meta-analysis. Consequently, only 51 articles were considered for full-text review. After full-text review, 45 articles were removed: studies with no quantitative measures of hepatitis C virus in pregnant women; studies that were not conducted in Ethiopia; studies that provided combined HCV and hepatitis B virus prevalence; studies that did not meet the eligibility criteria. Finally, 6 articles were identified as eligible for meta-analysis. The overall selection process of studies was undertaken according to PRISMA flow diagram (Figure
PRISA flow diagram of study selection for systematic review and meta-analysis of HCV infection among pregnant women in Ethiopia, 2020.
Five primary studies that fulfilled the eligibility criteria were institutional-based cross-sectional studies and one was community-based cross-sectional. The studies were conducted from 2013 to 2017 and published from 2014 to 2019. The sample size among studies ranged from the smallest 222 [
Descriptive summary of primary studies included in the systematic review and meta-analysis of HCV prevalence among pregnant women in Ethiopia, 2020.
First author | Year | Region | Study area | Study design | Sample size | Participants | Case | Response rate (%) | Prevalence (%) |
---|---|---|---|---|---|---|---|---|---|
Temesgen and Andamlak | 2019 | SNNPR | Atat Hospital | Cross-sectional | 222 | 222 | 4 | 100 | 1.801802 |
Yohannes et al. | 2015 | Amhara | Bahir Dar city | Cross-sectional | 318 | 318 | 2 | 100 | 0.628931 |
Mohammed et al. | 2014 | Amhara | Dessie referral hospital | Cross-sectional | 385 | 385 | 3 | 100 | 0.779221 |
Sefinew et al. | 2015 | Amhara | Felege Hiwot referral hospital | Cross-sectional | 384 | 384 | 1 | 100 | 0.260417 |
Belayne et al. | 2019 | Oromia | Jimma | Cross-sectional | 455 | 387 | 9 | 87 | 2.325581 |
Regea and Eyasu | 2018 | Oromia | East Wollega zone | Cross-sectional | 422 | 421 | 34 | 99.8 | 8.07601 |
The quality of each study included in this systematic review and meta-analysis was critically evaluated using a critical appraisal checklist for observational studies adopted from the Joanna Briggs Institute (JBI). Four of the studies (66.7%) scored ≥7 “yes” out of 8 on the quality assessment scale which is ≥87.5% and determined to be of high quality. Two of the studies (33.3%) were demeaned moderate quality as they scored 6 “yes” out of 8 on the quality scale assessment which is 75% (Table
Joanna Briggs Institute Critical Appraisal Checklist for analytical cross-sectional studies, 2020.
Studies | Clear criteria for inclusion | Detailed description of study subject and setting | Reliability and validity of study tools | Used standard criteria or objective | Identify cofounding factor | Strategy dealing with cofounders | Outcome measured within a valid way | Appropriate statistical analysis used | Overall score (%) |
---|---|---|---|---|---|---|---|---|---|
Temesgen and Andamlak | Yes | Yes | Yes | Yes | Yes | No | Yes | Yes | 87.5 |
Yohannes et al. | Yes | Yes | No | Yes | Yes | No | Yes | Yes | 75 |
Mohammed et al. | Yes | Yes | Yes | Yes | Yes | No | Yes | Yes | 87.5 |
Sefinew et al. | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | 100 |
Belayne et al. | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | 100 |
Regea and Eyasu | Yes | Yes | No | Yes | Yes | No | Yes | Yes | 75 |
In the current meta-analysis, a total of 2117 pregnant women were involved. The overall pooled prevalence of HCV infection among pregnant women in Ethiopia was 1.83% (95% CI: 0.61, 3.06). The I2 statistics for HCV infection among pregnant women was
Forest plot of the pooled prevalence of HCV infection among pregnant women in Ethiopia, 2020.
A metaregression analysis was done based on the categorical variables including sample size, year of publication, quality of included paper, and screening methods that primary studies have used. Accordingly, the analysis shows that all the variables included in the metaregression analysis had no significant effect on the pooled prevalence of HCV infection among pregnant women in Ethiopia (Table
Results of bivariate metaregression for the prevalence of HCV infection among pregnant women in Ethiopia, 2020.
Covariate | Category | Number of studies | Std. err. | Metaregression coefficient | Adjusted | |
---|---|---|---|---|---|---|
Year of publication | Until 2015 | 3 | 2.683904 | 3.236623 | 0.154 | −29.99 |
After 2015 | 3 | 2.82759 | −2.683904 | 0.396 | ||
Sample size | <384 | 2 | 2.602811 | 1.438686 | 0.610 | −24.68 |
>384 | 4 | 4.501046 | −2443958 | 0.959 | ||
Screening method used | Rapid test | 4 | 2.645513 | −1.055988 | 0.710 | 0.46 |
ELISA | 2 | 3.760814 | 3.569947 | 0.396 | ||
Quality of papers | Good | 4 | 2.355038 | 2.69041 | 0.317 | 41.88 |
Medium | 2 | 3.291085 | −1.430298 | 0.686 |
Since this meta-analysis exhibited considerable heterogeneity, subgroup analysis was done using regions (where the studies were conducted) to identify the possible sources of heterogeneity among the studies. The subgroup analysis indicated that the heterogeneity level was the highest among pregnant women (
Subgroup analysis of HCV infection pooled prevalence estimation among pregnant women in Ethiopia, 2020.
Publication bias among the included studies for this meta-analysis was checked using visual inspection of the shape funnel plots and statistical Egger’s test. The result of the tests revealed no evidence of publication bias according to Egger’s test (
Funnel plot with pseudo 95% confidence interval that investigated the publication bias of the pooled prevalence of HCV infection, Ethiopia, 2020.
The current systematic review and meta-analysis aimed to estimate the pooled prevalence of HCV infection among pregnant women in Ethiopia. The evidence obtained from this study may help healthcare workers and other concerned bodies to identify gaps in HCV screening during ANC; improve knowledge on the epidemiology of HCV infection among pregnant women in Ethiopia; and increase awareness of the general population regarding the epidemiology of HCV.
In this systematic review and meta-analysis, the prevalence of HCV infection among pregnant women in Ethiopia is close to the WHO endemicity definition of HCV infection [
The overall pooled prevalence of HCV infection among pregnant women in Ethiopia was 1.83% (95% CI: 0.61, 3.06). Although there was no comparable meta-analysis study conducted on this specific research question, this finding is consistent with WHO intermediate definition of HCV infection (1.5%–3.5%) [
The present study covers three regions of Ethiopia. The result revealed that the prevalence of HCV among pregnant women was the highest (5.10%) in Oromia region, compared with 0.44% in Amhara and 1.80% in SNNPR. This prevalence variation in different regions of Ethiopia could be due to differences in sample size, sampling method, and screening service and difference in the efficiency of diagnostic kits used. Moreover, the variation might be due to the difference in behavioral characteristics of the study participants including sexual practices, medical exposure for the potential risk factors of HCV infection, and level of awareness and differences in cultural practices.
The prevalence estimates in this meta-analysis are likely to show the current situation of HCV infection among pregnant women in Ethiopia because the included studies were conducted in more recent years. The introduction of language bias is expected as articles published only in the English language were included. In addition, the heterogeneity across selected studies was high, but important sources of heterogeneity were not fully addressed. Subsequently, the question about the methodological rigor of the review may raise as the review process was conducted with a single author. Selection bias in the estimation of community prevalence may be introduced as many of the studies included in the meta-analysis recruited participants from the referral hospitals. Moreover, this meta-analysis represented only studies reported from three regions of Ethiopia, which could affect the estimated prevalence reported and its representatives.
This systematic review and meta-analysis confirmed the intermediate level of HCV infection among pregnant women in Ethiopia. The finding of this study suggests the need to implement a routine and universal HCV screening program for all pregnant women, which enables women to access HCV antiviral treatment to minimize vertical transmission to newborn infants. Moreover, national and regional health programs should mandate and monitor the screening procedures so as to reduce the risk of hepatitis C virus infection. Furthermore, increasing awareness on modes of transmission and prevention of HCV should be considered.
Antenatal care
Confidence interval
Hepatitis C virus
Joanna Briggs Institute
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
Southern Nations Nationalities and People Region
World Health Organization.
All relevant data are included within the manuscript.
The author declares that there are no conflicts of interest.
BDM designed the study; extracted, critically reviewed, and analyzed data; and wrote the manuscript. Finally, the author has read and approved the manuscript.
Supplementary file 1: example of searches for the PubMed databases to assess the prevalence of HCV among pregnant women in Ethiopia.