Mother-to-child transmission of hepatitis B: extent of knowledge of physicians and midwives in Eastern region of Ghana

Hepatitis B viral (HBV) infection remains a global public health challenge accounting for a significant proportion of deaths attributable to cancer worldwide [1]. The global estimate indicates that about 240 million individuals are chronically infected with HBV and approximately 780,000 deaths occur from the consequences of HBV infection annually [2]. A recent report by the World Health Organisation shows that the majority of persons living with HBV infection reside in low and middle income countries including Sub-Saharan Africa (SSA) and Asia [3]. Ghana is one of the West African countries which is hyper endemic of HBV with a prevalence estimate of 15 % of adult population [4].

There is evidence that the probability of HBV infection progressing from acute to chronic stage depends on the age at which a person becomes infected [3, 5, 6]. Infection in early life has a much higher risk of becoming chronic than later in life. About 80–90 % of neonates, and 30–50 % of children develop chronic HBV infection when exposed to the virus [2]. Also, they stand a higher risk of developing chronic liver disease including hepatocellular carcinoma and cirrhosis of the liver than those infected as adults [3].

It is well documented that perinatal transmission is an important source of HBV infection to newborns [5, 7], and therefore, HBV positive pregnant women predispose their infants to serious risk of transmission during birth [8]. The huge contribution of about 50 % perinatal transmission in high endemic countries makes its crucial to implement standard protocols and interventions which target prevention of MTCT of HBV infection [9, 10].

Centers for Disease Control and Prevention (CDC) recommends routine screening of pregnant women during the ante-natal period to identify those who are positive for hepatitis B surface antigen (HBsAg) [8]. In addition, administration of Hepatitis B vaccine and Hepatitis B immunoglobulin (HBIG) to newborns of HBV infected mothers within the first 12 h of birth remains an effective intervention, averting about 90–95 % of MTCT of HBV infections [2, 8, 9]. However, these measures are not well implemented in many health facilities in Ghana. A study conducted in the Eastern region of Ghana found that newborns to HBV infected mothers are not given hepatitis B vaccine and HBIG at birth except the routine vaccination which are administered at 6, 10, and 14 weeks after birth [11]. This according to the study happened although pregnant women were screened for HBsAg in the health facilities [11]. This is a huge gap in Ghana’s response to the burden of hepatitis B infection particularly with the high prevalence of HBsAg (10.6 to 16 %) among pregnant women in the country [11, 12].

Several studies have assessed the level of knowledge of pregnant women on HBV infection and the evidence indicates gaps in their knowledge [13–15]. However, only few studies have assessed physician and midwives levels of knowledge on prevention of MTCT of HBV infection [16, 17]. A study conducted in China revealed that, majority of perinatal nurses including obstetrics, maternity, labour and intensive care unit nurses were unaware of the risk of newborns to chronic HBV infection which influenced their poor preventive practices [16].

In Ghana, there is a dearth of empirical evidence on the level of knowledge of midwives and physicians on MTCT of HBV infection. This study therefore aimed at establishing a baseline data on the subject. This is significant considering the fact that, in Ghana, physicians and midwives are the core staff that request hepatitis B screening during pregnancy and administer hepatitis B vaccine and immunoglobulin to newborns at birth. More so, these staff serve as the main source of hepatitis B-related information for most clients [18]. The findings of this study will contribute to programme design that will meet the learning needs of the professionals and inform policy.

The general objective of this study was to examine the extent of knowledge of physicians and midwives on MTCT of HBV. The findings showed that, all physicians and midwives (100 %) enrolled in the study were aware of HBV infection. This finding is consistent with a 99 % (n = 94) HBV awareness level reported in Nigeria among doctors [22]. Perhaps, the recent publicity of the disease in the mass media and other social network in Ghana might have contributed to the increased level of awareness of the disease. Furthermore, the most cited source of HBV-related information in this study was previous medical or midwifery training school (56.3 %). This is lower than a study finding in China which showed that, 71.6 % of obstetric gynaecologist obtained hepatitis B information from their previous medical school [17]. This raises concern since little information on hepatitis B is communicated to student during training [18], coupled with the growing current evidence on viral hepatitis in general in recent times. This may have an implication on Ghana’s response to the burden of HBV since there is a high probability that these critical staff may rely on out-of-date hepatitis B-related information to practice.

More so, continuing professional education is noted to build the capacity of health professionals in terms of knowledge and skills after completion of formal education [23]. However, in this study, 49.2 % of the participants reported that, they have never attended a workshop/seminar on MTCT of HBV since they completed their training. The overall effect is that, these professionals may not be in tune with current evidence that support hepatitis B prevention, management, care and support. Generally, unlike HIV/AIDS which has received much support and funding for capacity building of health professionals [24], less attention has been paid to HBV infection in Ghana. This can be partially attributed to limited local research evidence to support the need for Hepatitis B programmes and few NGOs which champion hepatitis B agenda in the country.

Also, it is widely accepted that, administration of hepatitis B vaccine and immunoglobulin to newborns of positive HBsAg/HBeAg mothers within 12 h after birth is essential to prevent MTCT of HBV [2, 25]. Conversely, this study found that, 87.3 % did not know that there is a vaccine that when administered with hepatitis B Immunoglobulin to newborns of HBV infected mothers can prevent transmission of HBV infection from mother to newborn. This means that, the recommended strategy to prevent MTCT of HBV is not considered primarily by these study participants. A situation that may put babies born to hepatitis B infected mothers to a high risk of acquiring HBV infection especially in Ghana where up to about 16 % of pregnant women are documented to be HBsAg positive [11, 12]. Notwithstanding, CDC recommends that breastfeeding of infant should not be uneccessarily delayed until baby is fully immunised and therefore education can be focused on mothers to ensure that their nipples are devoid of cracks or bleeding [25].

Furthermore, 35.7 % considered caesarean section (C/S) as the most effective strategy to prevent mother to child transmission of HBV infection than any available vaccine. This indicates that, 35.7 % of the participants had a knowledge gap on simple and effective intervention for prevention of MTCT of HBV as recommended by WHO and CDC [2, 25]. This study finding contradict a survey report by Hu and colleagues on knowledge of obstetrics and gynaecology staff which revealed that, majority (86.2 %) of the respondents knew that caesarean section is needless in preventing MTCT of HBV [17]. This therefore suggests the need for education on the effectiveness of hepatitis B vaccine as against caesarean section in preventing HBV from mother-to-child.

This study further revealed that, physicians and midwives in the district mission hospitals showed a good knowledge on MTCT of HBV compared to the regional hospital in the Eastern region. This finding serves as awake up call to focus education on the most appropriate strategies for prevention of MTCT of HBV for physicians and midwives in the study area especially regional government hospital.

The outcome of the study showed that, both physicians and midwives on the average had good knowledge on MTCT of hepatitis B infection. However, there were some knowledge gap regarding effective preventive strategies such as the use of hepatitis vaccine and immunoglobulin to prevent mother-to-child transmission of HBV infection. Furthermore, about 49 % of the participants had never attended any workshop on MTCT of hepatitis B since completion of formal training. It is therefore important to build the capacity of health professionals particularly physicians and midwives as part of the strategies to prevent mother to child transmission of hepatitis B in the Eastern region of Ghana.

HBsAg, hepatitis B surface antigen; HBV, hepatitis B virus; MTCT, mother-to-child transmission