Abstract

Background: Despite substantial progress in prevention of mother-to-child transmission (PMTCT) programmes and widespread access to antiretroviral therapy (ART), maternal HIV infection remains associated with adverse maternal and neonatal outcomes in many high HIV-burden settings. This study compared maternal and perinatal outcomes among women living with HIV and HIV-negative women delivering at a tertiary referral hospital in the Eastern Cape Province, South Africa. Methods: A retrospective comparative cohort study was conducted using routinely collected clinical records of 600 women (300 HIV-positive and 300 HIV-negative) who delivered at Nelson Mandela Academic Hospital between January and December 2019. Maternal, obstetric, and neonatal characteristics were compared according to maternal HIV status. Associations were evaluated using chi-square tests, multivariable logistic regression, Kaplan–Meier survival analysis, and Cox proportional hazards regression models. Results: Women living with HIV were older, had higher parity, and were more likely to have documented anaemia and delayed antenatal care attendance than HIV-negative women. HIV-exposed pregnancies had higher frequencies of preterm birth (26.3% vs. 20.3%) and low birthweight (LBW). In adjusted analyses, maternal HIV-positive status remained independently associated with increased odds of LBW (AOR = 1.88; 95% CI: 1.18–3.00; p = 0.008). LBW was independently associated with neonatal intensive care unit (NICU) admission (AOR = 2.45; 95% CI: 1.46–4.11; p < 0.001) and an increased hazard of in-hospital neonatal mortality (HR = 2.40; 95% CI: 1.55–3.70; p < 0.001). Maternal HIV-positive status (HR = 1.75; 95% CI: 1.12–2.71; p = 0.015) and unsuppressed maternal viral load (HR = 2.05; 95% CI: 1.13–3.73; p = 0.018) were also associated with increased hazards of neonatal mortality. However, these findings should be interpreted cautiously, given the limited number of neonatal mortality events (n = 32). Among HIV-exposed infants with documented HIV test results, the observed mother-to-child transmission rate was 1.7%. However, incomplete infant follow-up and HIV testing data limited the precision of this estimate. Among women living with HIV, birthweight did not differ significantly according to the timing of ART initiation. Conclusions: In this tertiary referral hospital cohort, maternal HIV infection was associated with adverse maternal and neonatal outcomes, particularly anemia, preterm birth, and LBW. LBW emerged as an important predictor of neonatal morbidity and mortality. These findings support continued efforts to strengthen integrated HIV and maternal healthcare services, promote early antenatal care engagement, maintain maternal viral suppression, and improve monitoring and care of high-risk neonates. Given the retrospective observational design, incomplete follow-up for selected outcomes, limited numbers of neonatal mortality events, and the tertiary referral setting, the findings should be interpreted as associations rather than evidence of causal relationships and may not be generalizable to lower-level healthcare facilities or community-based obstetric populations.

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