CMV in Pregnancy: A Neglected Area in Maternal and Neonatal Health Policy in LMICs

Cytomegalovirus (CMV) is a common human herpesvirus, transmitted through close contact with infected body fluids and establishes lifelong latent infection. When primary or nonprimary maternal infection occurs during pregnancy, the virus can cross the placenta and infect the fetus, resulting in congenital cytomegalovirus (cCMV) infection. ¹ CMV infection in pregnancy remains 1 of the most overlooked public health concerns globally, ² despite being a leading cause of congenital infections and long-term neurodevelopmental disabilities, including sensorineural hearing loss.^3,4 With a global prevalence of 0.67%, cCMV infection rate is estimated to be approximately 3 times higher in low- and middle-income countries (LMICs) than in high-income countries (HICs), ⁵ and maternal CMV seroprevalence is also higher in LMICs and varies substantially by demographic and health-related factors. ⁶ Paradoxically, the regions with the higher antenatal CMV burden are those with the least research investment, clinical guidance, and policy attention. Despite the major lifelong burden of cCMV on social and economic implications, ⁷ it remains largely overlooked within maternal and neonatal health frameworks in LMICs, underscoring an urgent need to strengthen evidence generation and to integrate cCMV into public health priorities and policy planning.

Recent evidence of lowering the risk of cCMV transmission by valaciclovir has revived interest in antenatal CMV screening and treatment in several high-income countries. ⁸ The European Congenital Cytomegalovirus Initiative (ECCI) has already established a consensus recommendation for prenatal, neonatal, and postnatal management of CMV infection. ⁹ Ongoing research in Europe also includes health-economic evaluations exploring the cost-effectiveness of universal or targeted antenatal CMV screening.^{10 -12} Despite high antenatal CMV burden, LMICs substantially lack any standardized screening and treatment policies. The absence of guidelines is due to the scarcity of local data, limited research investment, and the lack of surveillance information in this area. While a few countries often report TORCH infection outcomes during pregnancy,^13,14 these information are project specific, and rarely provide detailed information on maternal CMV infection and neonatal sequelae. Even though the knowledge and awareness level of antenatal CMV among European healthcare providers are still uneven,^15,16 nevertheless, such investigations help refine educational and clinical approaches. Unfortunately, no comparable studies exist in LMICs, where healthcare professionals’ knowledge gaps are likely wider.

This knowledge and policy gap needs to be addressed. More epidemiological and implementation research is required in LMICs to understand the true burden, transmission dynamics, and outcomes of CMV in mothers and neonates. These should include the establishment of sentinel surveillance to generate reliable burden estimates, integration of cCMV considerations within existing antenatal and maternal-newborn health platforms, and prioritization of cCMV within broader maternal and child health agendas. Maternal and fetal medicine specialists, obstetricians, neonatologists, nurses, midwives, and public health researchers from LMICs should also begin prioritizing antenatal CMV as an area of clinical and research focus. Strengthening implementation research and health-system readiness will be essential to inform feasible screening, prevention, and care pathways in resource-constrained settings in the future.