Assessing the Scope of Evidence-Based Interventions and Policy Mobilization Efforts on CMV Infection Prevention in U.S. Pregnant Women: A Scoping Review

Abstract

Congenital CMV (cCMV) is the leading cause of hearing loss and neurodevelopmental disabilities in children, affecting 15–18% of births in the United States (U.S.). Despite its strong presence, the lack of routine prenatal screening limits its detection and prevention, especially in low-resource communities. The aim of this scoping review is to describe the scope of the CMV interventions and the policies on CMV screening in the United States, identify successful strategies for the implementation of improved CMV screening rates, and make recommendations for future efforts aimed at improving CMV screening in U.S. healthcare settings. The Joanna Briggs Institute recommendations for scoping reviews and the Arksey and O’Malley (2005) York methodology guided the different review steps. These included (1) identifying research questions; (2) searching for relevant studies; (3) selecting studies relevant to the research questions; (4) charting the data; (5) collating, summarizing, and reporting results. A total of six studies were retained for analysis. A common barrier reported across studies was the lack of generalizability of findings due to small sample size. Challenges encountered by patients often centered around awareness, emotional resistance, and cultural norms. Providers also faced significant barriers, particularly related to time constraints, knowledge gaps, and the prioritization of CMV education in prenatal care. Furthermore, a recurrent theme across included studies was the critical role of education in increasing awareness and reducing CMV transmission risks. Findings will contribute to the advancement of CMV prevention through the identification of gaps in education, policy, and practice, thus assuring better health outcomes for mothers and infants.

1. Introduction

Cytomegalovirus (CMV) is a common infection that affects individuals globally [1]. While immunocompetent individuals will typically be asymptomatic when infected, CMV infections can be particularly important to consider in pregnant women [2]. Congenital CMV (cCMV) is the leading cause of hearing loss and neurodevelopmental disabilities in children, affecting 15–18% of births in the United States (U.S.) [1]. Pregnant women are considered to be at a higher risk of CMV, specifically those that have frequent exposure to young children, close contact with bodily fluids, or other occupational risks [1]. Despite its strong presence, the lack of routine prenatal screening limits its detection and prevention, especially in low-resource communities [3,4].

There are a variety of challenges in screening for CMV among pregnant individuals in the United States. The lack of uniform guidelines regarding CMV screening during pregnancy makes its practice inconsistent across healthcare facilities and providers [4]. Because there is no effective therapy for CMV in pregnancy, screening is not always recommended [2]. Additionally, there is a limited amount of information about CMV and its health outcomes, making it more difficult for pregnant individuals to gain adequate knowledge about this topic and how it can impact them [5]. Moreover, challenges in interpretation of serological tests persist due to false positives emerging from re-activated infections, which makes it difficult to determine the timing and nature of infection [6]. Financial and logistical issues such as out-of-pocket expenses and disparities in access to healthcare also play a role in the limited knowledge that some communities may have in relation to CMV [7]. Furthermore, cultural and linguistic barriers in the healthcare setting that minority populations may face also play a role in the lower rates of CMV testing [3].

Current U.S. policies related to CMV screening are quite limited in the guidance provided to pregnant individuals when making informed health decisions. While there are professional organizations such as the American College of Obstetricians and Gynecologists (ACOG) providing recommendations on CMV prevention strategies for pregnant individuals, such efforts often do not translate to routine screening [8]. Despite the presence of state-level initiatives that attempt to address CMV education and prevention, measured impact and respective outcomes remain fragmented, leading to inconsistent awareness of this infection and a significant gap in implementation of effective education and screening strategies across healthcare systems [8].

Currently, the scope of evidence-based educational and public policy interventions aiming to increase awareness of CMV among pregnant individuals and healthcare providers remains limited, particularly when it comes to tailoring screening strategies and educational messages to be culturally responsive to the growing diversity of the U.S. pregnant population [7,9]. Examples of such campaigns that focus on patient education include social media messaging, community-based education, and distribution of informational resources in community-based settings and healthcare settings [4,5]. Initiatives that emphasize provider education include trainings to bridge knowledge gaps [10]. Despite these advancements in this realm, there is a need to have inclusivity and broader representation of U.S. minority pregnant women who are at higher risk of having CMV infections due to low health literacy, medical history, and environmental risk factors [9,10]. Therefore, it is necessary for screening processes, educational programs, policies, and community-based engagement to work in tandem in order to effectively implement change in the communities that are at a higher risk for CMV infection.

The aim of this scoping review is to describe the scope of the CMV interventions and the policies on CMV screening in the United States, identify successful strategies for the implementation of improved CMV screening rates, and make recommendations for future efforts aimed at improving CMV screening in U.S. healthcare settings. This study will contribute to the advancement of CMV prevention through the identification of gaps in education, policy, and practice, thus assuring better health outcomes for mothers and infants.

2. Methods

The review team encompassed a team of health professionals including public health experts, physicians, medical students, and health education professionals. The review followed the York methodology by Arksey and O’Malley (2005) [11] and incorporated recommendations from the Joanna Briggs Institute (JBI) [12] for the extraction, analysis, and presentation of results in scoping reviews. The study sections were developed using the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) as a checklist reference [13].

2.1. Step 1. Guiding Research Questions

This review was guided by three questions:

• What is the scope of CMV educational and screening interventions for CMV prevention in U.S. pregnant women?
• What are the barriers encountered in the dissemination and implementation of evidence-based interventions addressing CMV infections in U.S. pregnant women?
• What are future recommendations to improve CMV screening rates in U.S. healthcare settings?

2.2. Step 2. Review Process and Criteria

A senior research librarian (TF), who has extensive experience in scoping and systematic review protocols, developed, narrowed, and finalized the search strategy for this review (Supplementary Materials). Search terms included cytomegalovirus (CMV), pregnancy, CMV infection, CMV screening, pregnant women, health providers, physicians, primary care, obstetrics and gynecology, intervention, education, policy efforts, mobilization efforts, and screening guidelines. The search strategy was then modified and imputed across three databases selected for their breadth and depth of articles on our topic of interest. These databases consisted of PubMed, Embase, and Cochrane Library. Review of the literature was completed from July 2024 to November 2024, and initial screening of the articles was carried out by co-authors (JS, DL, SF, VJ, MF, and KL). Secondary screening and full-text article screening were conducted by senior author (LS).

2.2.1. Inclusion Criteria

Included articles were published in English between 2014 and 2024 and either explored the availability of evidence-based interventions and programs aiming to improve CMV screening rates for early detection and prevention in at-risk U.S. pregnant women or focused on the scope of policy and mobilization efforts aimed at raising awareness on the importance of CMV screenings. Studies should also be conducted in the United States and include pregnant women at risk of acquiring CMV. The reason behind the timeframe selection was exploring the most recent updates on CMV screening policies and newer implemented interventions to improve screening and early detection rates in pregnant women with CMV to prevent both maternal and fetal adverse outcomes.

2.2.2. Exclusion Criteria

Articles were excluded if they did not focus on the role of policy efforts and/or educational efforts in improving adherence to recommended CMV screening guidelines in pregnant women. Studies carried out outside the United States or published in foreign languages or outside selected time frame were also excluded. Finally, published abstracts were also excluded from consideration.

2.3. Step 3. Data Summarization

All co-authors (JS, DL, SF, VJ, MF, and KL) extracted and summarized data for tabulation. Senior author (LS) reviewed all tabulated data to resolve any discrepancies in data extraction.

Table 1. Study characteristics.

Article Number	Primary Author/ Year	Study Design	Sample Size	Study Population	Age Range	Study Purpose	Outcome of Interest	CMV Educational/Screening Intervention	Type of Intervention Developed/Implemented	Resources Used in Intervention Delivery	Major Intervention Outcomes	CMV Policy and/or Mobilization Efforts	Type of Policy Discussed/Implemented	Major Policy Outcomes
1	Albleft et al., 2019 [14]	Decision Analysis	n = 4,000,000	Theoretical cohort of women pregnant annually in the US	Average 26 years old (estimated)	To determine the necessary effectiveness of intravenous hyperimmune globulin (HIG) as well as targeted behavioral counseling for prevention of congenital CMV To determine the threshold incidence of primary CMV that would make universal maternal CMV screening in pregnancy cost-effective	The cost per maternal quality-adjusted life year (QALY) gained with a willingness to pay of $100,000 per QALY	No	N/A	N/A	N/A	Yes	Universal prenatal serum screening (Assumed that all pregnant women underwent one-time serum screening for CMV prior to 20 weeks of gestation) o Routine, risk-based screening Screen-positive women received monthly HIG, and screen-negative women received behavioral counseling to decrease CMV seroconversion Base case assumptions: probability of primary CMV of 1% in seronegative women, hyperimmune globulin (HIG) effectiveness of 0%, and behavioral intervention effectiveness of 85%	Universal screening is cost-effective, costing $84,773 per maternal QALY gained In sensitivity analyses, universal screening is cost-effective only at a primary CMV incidence of more than 0.89% and behavioral intervention effectiveness of more than 75% Behavioral counseling is effective if lower rates of primary CMV If HIG is 30% effective, primary CMV incidence can be 0.82% for universal screening to be cost-effective
2	Hughes et al., 2017 [15]	Randomized Controlled Trial	n = 180	Women without serologic evidence of primary CMV infection (initially screened with CMV serology during prenatal care before 20 weeks of gestation and followed for at least 10 weeks)	N/A	To estimate the effects of a brief prenatal behavioral intervention on risk behaviors for maternal cytomegalovirus (CMV) infection.	Primary Outcome: Change in behavioral compliance score on a scale of 0–100. Secondary Outcome: Process evaluation and domains of behavior change	Yes	In-Office Intervention (video and hygiene education through a brochure), a reminder set on their calendar, and weekly text message reminders	Brief behavioral intervention via video and motivational interviewing about hygiene education, delivered in the prenatal care setting	Baseline behavioral compliance scores increased modestly in the intervention group compared with the comparison group Intervention group reported change in risk perception related to perceived severity and susceptibility, self-efficacy, and perceived norms	No	N/A	N/A
3	Levis et al., 2017 [16]	Cross-sectional	n = 30 (in-depth interview) n = 70 (focus groups)	Women who had young children who tested positive for CMV (In-depth interviews) Pregnant women and non-pregnant women who had young children in Atlanta and San Diego (Focus group interviews)	18–45 years old	To evaluate how fear-appeal theory-based messages about CMV prevention influence recipients to take action	Increase practice of prevention strategies	No	Interview-based intervention using fear appeal messages	Messages created around fear appeals theory-based communication concept Using stories to demonstrate prevention strategies Including messages about risk reduction when introducing prevention strategies	To convey the severity of CMV, participants preferred stories about CMV along with prevention strategies Participants also welcomed prevention strategies when it included a message about risk reduction	No	N/A	N/A
4	Price et al., 2014 [17]	Cohort	n = 809	African American and Caucasian women who had a young child and were either pregnant or planning a pregnancy	18–40 years old	To determine if CMV education materials increase knowledge about CMV and motivate audiences to seek additional information on CMV and adopt CMV prevention behavior	Improve women’s knowledge of CMV and encourage them to adopt prevention behaviors	Yes	Web-based CMV education via factsheet or video	Education via a one-page factsheet define CMV infection, explaining how pregnant women acquire the infection, and how women can reduce their risk of becoming infected Education via a 5 min video of a Black mother sharing her experience of having a baby born with congenital CMV infection and how risk of CMV infection can be reduced	Health education materials can improve women’s knowledge and awareness of CMV Women educated on CMV have increased motivation to practice CMV prevention behaviors Education materials may also encourage women to engage in behaviors that will reduce their exposures to CMV during pregnancy	No	N/A	N/A
5	Schaefer et al., 2020 [18]	Cohort	n = 263	Women receiving prenatal care at the Women’s Health Specialist Clinic associated with the Department of OBGYN and Women’s Health at the University of Minnesota	18–44 years old	To assess pregnant women’s knowledge and understanding of CMV infection during pregnancy and develop an educational tool about CMV infection to be utilized during prenatal care	Increase awareness of CMV infection in pregnancy	Yes	Educational handout about CMV infection in pregnancy	CMV educational handouts designed by the study authors using references from the CDC, the Society for Maternal Fetal Medicine, and the American College of Obstetricians and Gynecologists	Pregnant women viewed education about CMV favorably Participants increased the frequency of recommended hygiene practices	Yes	Introducing an educational handout to routine prenatal care may be beneficial in increasing awareness of CMV infection in pregnancy	N/A
6	Thackeray et al., 2017 [19]	Cross-sectional	n = 840	Online panel of women 18–40 years, who were pregnant or planning a pregnancy	18–40 years old	To evaluate the effect of message framing on women’s intention to perform cytomegalovirus (CMV) prevention behaviors	Increase CMV prevention behaviors	Yes	Web-based CMV fact sheet educational material	CMV fact sheets educational materials provided to women who were pregnant or planning a pregnancy CMV prevention behaviors presented in terms of gains or losses to the patient practicing these behaviors	Framing CMV messages by what women stand to gain or lose interacts with perceived behavioral control and response efficacy to influence behavioral intention Education on avoiding kissing children on the lips and sharing food with children show greater gain in CMV prevention behaviors	No	N/A	N/A

Table 1. Study characteristics.

Article Number	Primary Author/ Year	Study Design	Sample Size	Study Population	Age Range	Study Purpose	Outcome of Interest	CMV Educational/Screening Intervention	Type of Intervention Developed/Implemented	Resources Used in Intervention Delivery	Major Intervention Outcomes	CMV Policy and/or Mobilization Efforts	Type of Policy Discussed/Implemented	Major Policy Outcomes
1	Albleft et al., 2019 [14]	Decision Analysis	n = 4,000,000	Theoretical cohort of women pregnant annually in the US	Average 26 years old (estimated)	To determine the necessary effectiveness of intravenous hyperimmune globulin (HIG) as well as targeted behavioral counseling for prevention of congenital CMV To determine the threshold incidence of primary CMV that would make universal maternal CMV screening in pregnancy cost-effective	The cost per maternal quality-adjusted life year (QALY) gained with a willingness to pay of $100,000 per QALY	No	N/A	N/A	N/A	Yes	Universal prenatal serum screening (Assumed that all pregnant women underwent one-time serum screening for CMV prior to 20 weeks of gestation) o Routine, risk-based screening Screen-positive women received monthly HIG, and screen-negative women received behavioral counseling to decrease CMV seroconversion Base case assumptions: probability of primary CMV of 1% in seronegative women, hyperimmune globulin (HIG) effectiveness of 0%, and behavioral intervention effectiveness of 85%	Universal screening is cost-effective, costing $84,773 per maternal QALY gained In sensitivity analyses, universal screening is cost-effective only at a primary CMV incidence of more than 0.89% and behavioral intervention effectiveness of more than 75% Behavioral counseling is effective if lower rates of primary CMV If HIG is 30% effective, primary CMV incidence can be 0.82% for universal screening to be cost-effective
2	Hughes et al., 2017 [15]	Randomized Controlled Trial	n = 180	Women without serologic evidence of primary CMV infection (initially screened with CMV serology during prenatal care before 20 weeks of gestation and followed for at least 10 weeks)	N/A	To estimate the effects of a brief prenatal behavioral intervention on risk behaviors for maternal cytomegalovirus (CMV) infection.	Primary Outcome: Change in behavioral compliance score on a scale of 0–100. Secondary Outcome: Process evaluation and domains of behavior change	Yes	In-Office Intervention (video and hygiene education through a brochure), a reminder set on their calendar, and weekly text message reminders	Brief behavioral intervention via video and motivational interviewing about hygiene education, delivered in the prenatal care setting	Baseline behavioral compliance scores increased modestly in the intervention group compared with the comparison group Intervention group reported change in risk perception related to perceived severity and susceptibility, self-efficacy, and perceived norms	No	N/A	N/A
3	Levis et al., 2017 [16]	Cross-sectional	n = 30 (in-depth interview) n = 70 (focus groups)	Women who had young children who tested positive for CMV (In-depth interviews) Pregnant women and non-pregnant women who had young children in Atlanta and San Diego (Focus group interviews)	18–45 years old	To evaluate how fear-appeal theory-based messages about CMV prevention influence recipients to take action	Increase practice of prevention strategies	No	Interview-based intervention using fear appeal messages	Messages created around fear appeals theory-based communication concept Using stories to demonstrate prevention strategies Including messages about risk reduction when introducing prevention strategies	To convey the severity of CMV, participants preferred stories about CMV along with prevention strategies Participants also welcomed prevention strategies when it included a message about risk reduction	No	N/A	N/A
4	Price et al., 2014 [17]	Cohort	n = 809	African American and Caucasian women who had a young child and were either pregnant or planning a pregnancy	18–40 years old	To determine if CMV education materials increase knowledge about CMV and motivate audiences to seek additional information on CMV and adopt CMV prevention behavior	Improve women’s knowledge of CMV and encourage them to adopt prevention behaviors	Yes	Web-based CMV education via factsheet or video	Education via a one-page factsheet define CMV infection, explaining how pregnant women acquire the infection, and how women can reduce their risk of becoming infected Education via a 5 min video of a Black mother sharing her experience of having a baby born with congenital CMV infection and how risk of CMV infection can be reduced	Health education materials can improve women’s knowledge and awareness of CMV Women educated on CMV have increased motivation to practice CMV prevention behaviors Education materials may also encourage women to engage in behaviors that will reduce their exposures to CMV during pregnancy	No	N/A	N/A
5	Schaefer et al., 2020 [18]	Cohort	n = 263	Women receiving prenatal care at the Women’s Health Specialist Clinic associated with the Department of OBGYN and Women’s Health at the University of Minnesota	18–44 years old	To assess pregnant women’s knowledge and understanding of CMV infection during pregnancy and develop an educational tool about CMV infection to be utilized during prenatal care	Increase awareness of CMV infection in pregnancy	Yes	Educational handout about CMV infection in pregnancy	CMV educational handouts designed by the study authors using references from the CDC, the Society for Maternal Fetal Medicine, and the American College of Obstetricians and Gynecologists	Pregnant women viewed education about CMV favorably Participants increased the frequency of recommended hygiene practices	Yes	Introducing an educational handout to routine prenatal care may be beneficial in increasing awareness of CMV infection in pregnancy	N/A
6	Thackeray et al., 2017 [19]	Cross-sectional	n = 840	Online panel of women 18–40 years, who were pregnant or planning a pregnancy	18–40 years old	To evaluate the effect of message framing on women’s intention to perform cytomegalovirus (CMV) prevention behaviors	Increase CMV prevention behaviors	Yes	Web-based CMV fact sheet educational material	CMV fact sheets educational materials provided to women who were pregnant or planning a pregnancy CMV prevention behaviors presented in terms of gains or losses to the patient practicing these behaviors	Framing CMV messages by what women stand to gain or lose interacts with perceived behavioral control and response efficacy to influence behavioral intention Education on avoiding kissing children on the lips and sharing food with children show greater gain in CMV prevention behaviors	No	N/A	N/A

Table 2. Barriers encountered in the design, dissemination, implementation, and/or sustainability of evidence-based CMV screening interventions and policy efforts.

Article Number	Primary Author/Year	Overview of Barriers to CMV Prevention Measures	Barriers Encountered by Patients	Barriers Encountered by Providers
1	Albleft et al., 2019 [14]	HIG was assumed to be ineffective due to not having proven efficacy and being only recommended within a research study. Also, lacks data in IUFD and preterm delivery Not accounting for risk of reinfection in seropositive women Did not model a behavioral intervention who were CMV positive Did not model universal neonatal CMV screening because it is not standard of care Only modeled treatment for long-term severe disability from CMV, did not include mild to moderate hearing loss caused by CMV Based on assumptions and available data Lack of generalizability	N/A	N/A
2	Hughes et al., 2017 [15]	Sample size not large enough to assess whether intervention affected seroconversion Potential Hawthorne effect, in comparison group having an increase in compliance during time of screening	N/A	N/A
3	Levis et al., 2017 [16]	N/A	Patients were not previously aware of CMV risk Some patients felt sad to implement behaviors such as refraining from kissing their child on the lips Study participants were made aware of their CMV serostatus Those who were seropositive were less interested in prevention behaviors because they knew they were already infected	While participants found messages to be motivating, they felt that it could be difficult to make certain behavior changes
4	Price et al., 2014 [17]	While appealing, knowledge of CMV, and motivation to engage in CMV prevention behaviors is elevated immediately following education, the impact may be diminished over time	N/A	N/A
5	Schaefer et al., 2020 [18]	The study population was predominantly white and well educated, limiting the generalizability of the findings Patients with lower health literacy levels could potentially have decreased outcomes	Availability of CMV education in obstetric clinics	Limited time during prenatal care visits Low CMV knowledge among obstetrical providers A lack of understanding about the significance of CMV
6	Thackeray et al., 2017 [19]	N/A	Some behaviors are rooted in cultural norms which could have significant mental and emotional costs if changed	Unwillingness of patients to modify their behaviors

Table 2. Barriers encountered in the design, dissemination, implementation, and/or sustainability of evidence-based CMV screening interventions and policy efforts.

Article Number	Primary Author/Year	Overview of Barriers to CMV Prevention Measures	Barriers Encountered by Patients	Barriers Encountered by Providers
1	Albleft et al., 2019 [14]	HIG was assumed to be ineffective due to not having proven efficacy and being only recommended within a research study. Also, lacks data in IUFD and preterm delivery Not accounting for risk of reinfection in seropositive women Did not model a behavioral intervention who were CMV positive Did not model universal neonatal CMV screening because it is not standard of care Only modeled treatment for long-term severe disability from CMV, did not include mild to moderate hearing loss caused by CMV Based on assumptions and available data Lack of generalizability	N/A	N/A
2	Hughes et al., 2017 [15]	Sample size not large enough to assess whether intervention affected seroconversion Potential Hawthorne effect, in comparison group having an increase in compliance during time of screening	N/A	N/A
3	Levis et al., 2017 [16]	N/A	Patients were not previously aware of CMV risk Some patients felt sad to implement behaviors such as refraining from kissing their child on the lips Study participants were made aware of their CMV serostatus Those who were seropositive were less interested in prevention behaviors because they knew they were already infected	While participants found messages to be motivating, they felt that it could be difficult to make certain behavior changes
4	Price et al., 2014 [17]	While appealing, knowledge of CMV, and motivation to engage in CMV prevention behaviors is elevated immediately following education, the impact may be diminished over time	N/A	N/A
5	Schaefer et al., 2020 [18]	The study population was predominantly white and well educated, limiting the generalizability of the findings Patients with lower health literacy levels could potentially have decreased outcomes	Availability of CMV education in obstetric clinics	Limited time during prenatal care visits Low CMV knowledge among obstetrical providers A lack of understanding about the significance of CMV
6	Thackeray et al., 2017 [19]	N/A	Some behaviors are rooted in cultural norms which could have significant mental and emotional costs if changed	Unwillingness of patients to modify their behaviors

Table 3. Future recommendations for the development and implementation of CMV screening and prevention efforts.

Article Number	Primary Author/Year	List of Recommendations
1	Albleft et al., 2019 [14]	If the results of the ongoing studies of treatment efficacy of HIG for primary maternal CMV demonstrate an efficacy of 30% along with an incidence of primary CMV of more than 0.82%, universal screening may be cost-effective If the ongoing studies do not demonstrate HIG efficacy, universal CMV screening is still cost-effective as long as the incidence of CMV remains above 0.89% If primary prevention of CMV using behavioral intervention is more effective than expected, universal screening will remain cost-effective at a lower CMV incidence Current analysis may help guide policy in the future once more accurate data from the evaluation of HIG in primary maternal CMV
2	Hughes et al., 2017 [15]	In provider offices, video can be shown in the waiting room and brief motivational counseling can be given by a staff member
3	Levis et al., 2017 [16]	More should be done to increase awareness of CMV risk to pregnant patients Regular audience testing with pregnant women while awareness of CMV remains low should be conducted Gain-framed messages that highlight the benefits of having a healthy baby when following CMV prevention strategies could be beneficial to test in future studies
4	Price et al., 2014 [17]	The potential impact of health education materials requires further exploration regarding the extent to which viewing the materials can lead to behavior changes The extent of reductions in the risk of acquiring CMV infection in pregnant women who were educated on CMV should be studied further
5	Schaefer et al., 2020 [18]	Obstetrical providers should incorporate CMV education into their routine prenatal care
6	Thackeray et al., 2017 [19]	Future studies should focus on identification of factors that are most persuasive when trying to influence women’s CMV preventative behaviors Messaging that focuses on increasing perceived behavioral control and response efficacy, particularly for the kissing and sharing behaviors, may result in greater gains in intention The method of framing CMV educational materials interacts with the perception of effectiveness of CMV preventing behaviors. This should be kept in mind while designing and implementing further CMV educational interventions

Table 3. Future recommendations for the development and implementation of CMV screening and prevention efforts.

Article Number	Primary Author/Year	List of Recommendations
1	Albleft et al., 2019 [14]	If the results of the ongoing studies of treatment efficacy of HIG for primary maternal CMV demonstrate an efficacy of 30% along with an incidence of primary CMV of more than 0.82%, universal screening may be cost-effective If the ongoing studies do not demonstrate HIG efficacy, universal CMV screening is still cost-effective as long as the incidence of CMV remains above 0.89% If primary prevention of CMV using behavioral intervention is more effective than expected, universal screening will remain cost-effective at a lower CMV incidence Current analysis may help guide policy in the future once more accurate data from the evaluation of HIG in primary maternal CMV
2	Hughes et al., 2017 [15]	In provider offices, video can be shown in the waiting room and brief motivational counseling can be given by a staff member
3	Levis et al., 2017 [16]	More should be done to increase awareness of CMV risk to pregnant patients Regular audience testing with pregnant women while awareness of CMV remains low should be conducted Gain-framed messages that highlight the benefits of having a healthy baby when following CMV prevention strategies could be beneficial to test in future studies
4	Price et al., 2014 [17]	The potential impact of health education materials requires further exploration regarding the extent to which viewing the materials can lead to behavior changes The extent of reductions in the risk of acquiring CMV infection in pregnant women who were educated on CMV should be studied further
5	Schaefer et al., 2020 [18]	Obstetrical providers should incorporate CMV education into their routine prenatal care
6	Thackeray et al., 2017 [19]	Future studies should focus on identification of factors that are most persuasive when trying to influence women’s CMV preventative behaviors Messaging that focuses on increasing perceived behavioral control and response efficacy, particularly for the kissing and sharing behaviors, may result in greater gains in intention The method of framing CMV educational materials interacts with the perception of effectiveness of CMV preventing behaviors. This should be kept in mind while designing and implementing further CMV educational interventions

Summary tables included one evidence table describing study characteristics such as study population, age range, outcome of interest, and major findings from implemented interventions (Table 1). Table 2 highlights CMV screening-related barriers encountered in the design, dissemination, and implementation of educational interventions, along with barriers encountered by physicians and patients themselves when it comes to CMV screening. Table 3 provides future recommendations for the design and implementation of CMV screening and educational interventions as well as considerations in policy design and dissemination to reduce CMV infection rates in pregnant women

2.4. Steps 4 and 5. Data Charting and Collation, Summarization, and Reporting of Results

Table 1 summarizes study characteristics, types of educational interventions implemented, resources used for intervention delivery, and major intervention outcomes. It also highlights drafted policies and mobilization efforts conducted to improve CMV screening rates. Table 2 highlights barriers encountered in the design, dissemination, implementation, and/or sustainability of evidence-based CMV screening interventions and policy efforts as well as barriers encountered by physicians to recommend CMV screenings, along with barriers experienced by pregnant women in adhering to those recommendations. Finally, Table 3 provides future directions for researchers by emphasizing recommendations that should be taken into consideration when designing and implementing evidence-based intervention and policies related to CMV screening and prevention during pregnancy.

3. Results

The initial study extraction resulted in 1979 articles from PubMed (n = 833), EMBASE (n = 2033), Cochrane Library (n = 102). Following a full-text review, exclusion of duplicates, and exclusion of articles that did not meet our inclusion criteria, a total of six studies were retained for analysis (Figure 1). The retained articles were published between 2014 and 2022. The study designs included decision analysis (n = 1), randomized controlled trial (n = 1), cross-sectional (n = 2), and cohort (n = 2). Study sample size ranged from n = 100 to n= 4,000,000 with individuals studied commonly being aged 18–45. Five of the six studies (83%) implemented an intervention for educating their target populations regarding CMV. Two of the six studies (33%) shared policy or mobilization efforts to create routine, wide-spread awareness of CMV infection in pregnant populations.

3.1. Availability of CMV Educational Interventions for CMV Prevention in Pregnant Women

Interventions utilized for CMV awareness, as highlighted in the included studies, relied heavily on delivery vehicles such as web-based fact sheets and educational materials (n = 2), physical handouts (n = 1), and digital follow-up reminders to patients (n = 1), or consisted of interview-based interventions (n = 1). Both interventions highlighted in Thackeray et al.’s [19]. and Price et al.’s [17] studies employed web-based CMV education via fact sheets provided to pregnant women and those planning to become pregnant. Price et al. [17] also distributed a testimonial video of a mother sharing her personal experience of having a baby born with congenital CMV and the longitudinal challenges accompanying such a diagnosis to improve awareness of the disease and call for early detection and adherence to recommended prevention measures. Moreover, physical educational handouts used by Schaefer et al. [18] referenced facts from the CDC, the Society for Maternal Fetal Medicine, and the American College of Obstetricians and Gynecologists. Such material showed outcomes of increased motivation to practice CMV prevention behaviors and highlighted that example-based hygiene education such as recommendation to avoid transmission via sharing food or kissing lip-to-lip with children had greater gain in CMV prevention behaviors. Furthermore, prenatal in-office interventions conducted using educational videos and brochures as modalities of maternal reach and delivery, along with calendar and weekly text reminders to prenatal patients, showed increased baseline behavioral compliance and reported change in risk perception from patients [18]. Finally, the usage of fear appeal theory-based messages to influence action to screen for CMV emphasized the need for a combination of both story-based and theory-based messages to develop and implement effective CMV prevention strategies [16].

3.2. Scope of CMV Policies and Mobilization Efforts

Of the siex studies included in the scoping review, two focused on CMV policies and mobilization efforts. Albright et al. [14] used decision analysis to determine the threshold of factors, including CMV incidence as well as hyperimmune globulin (HIG) and behavioral counseling effectiveness, that can lead to cost-effective universal prenatal CMV screenings [14]. Using a theoretical cohort of 4,000,000 women, with an average age of 26 years and pregnant annually in the U.S., the study’s primary outcome was the cost per maternal quality-adjusted life year (QALY) gained, assuming a willingness to pay of $100,000 per QALY. The study split the cohort into two groups, one to undergo universal screening before 20 weeks gestational age (GA) and the other to undergo risk-based screening. If screenings were positive, patients would undergo monthly HIG infusions, and if negative, they were given the behavioral counseling to prevent later transmission. At a base-case assumption of primary CMV incidence of 1% in seronegative women, HIG effectiveness of 0%, and behavioral intervention effectiveness of 85%, universal screening is cost-effective at $84,773 per maternal QALY gained. Further sensitivity analyses determined universal screening is cost-effective at a primary CMV incidence of more than 0.89% and behavioral intervention effectiveness of more than 75%, or, if HIG is 30% effective, primary CMV incidence can be 0.82%. It was also found that behavioral counseling is effective if there are lower rates of primary CMV [14]. Another study focused on in-clinic education and behavior modification [18]. In this prospective cohort study of 263 women, researchers developed an educational tool using Centers for Disease Control and Prevention (CDC) guidelines to increase awareness of CMV infection in pregnancy. Participants were presented with pre- and post-surveys to determine CMV awareness and CMV risky behaviors (hand washing behaviors, sharing saliva with young child). The educational tool was viewed favorably by the pregnant woman, and participants decreased high-risk behaviors. Introducing educational material into routine prenatal care proved to be beneficial in increasing awareness of CMV infection in pregnancy [18]. Together, these studies underscore the importance of combining cost-effective CMV screening policies with educational and behavior modification efforts to enhance awareness and reduce infection risk in pregnant women.

3.3. Barriers Encountered in the Design, Dissemination, Implementation, and/or Sustainability of Evidence-Based CMV Screening Interventions and Policy Efforts

A range of barriers were encountered in the design, dissemination, and implementation of the six studies used in this scoping review. One prominent and common challenge across studies was the issue of small sample size and lack of generalizability. For example, Hughes et al. noted that their study’s limited sample size hindered their ability to assess whether the intervention significantly affected seroconversion rates [15]. Similarly, Schaefer et al. reported that their predominantly White, well-educated study population limited the generalizability of their findings to more diverse groups [18]. Albright et al. emphasized that their study relied heavily on assumptions and incomplete modeling, further reducing the broad applicability of their findings [14]. These constraints collectively reduce the reach and impact of these interventions among pregnant women most at risk of contracting CMV. Challenges encountered by patients often centered around awareness, emotional resistance, and cultural norms. Levis et al. reported that those who discovered they were already CMV-seropositive showed less interest in engaging in prevention behaviors [15]. Emotional costs, such as sadness or discomfort associated with changing behaviors like kissing their children on the lips, were commonly reported. Similarly, Thackeray et al. emphasized the mental and emotional toll of modifying culturally engrained behaviors, which could hinder intervention uptake [16].

Providers also faced significant barriers, particularly related to time constraints, knowledge gaps, and the prioritization of CMV education in prenatal care. Schaefer et al. explained that limited time during prenatal visits left little opportunity for providers to deliver CMV education effectively [13]. Furthermore, low CMV knowledge among obstetric providers and a lack of understanding of the infection’s significance were cited as key challenges. Thackeray et al. additionally pointed out that patient reluctance to modify behaviors created further challenges for providers in implementing preventative interventions [16]. These barriers collectively emphasize the value of addressing both systemic and individual-level challenges to improve the effectiveness and sustainability of CMV screening and prevention efforts.

3.4. Recommendations for Future CMV Prevention Interventions

Included studies offer valuable recommendations to improve CMV prevention, particularly through policy development and educational interventions. Albright et al. found universal prenatal CMV screenings to be cost-effective if the incidence of CMV is greater than 0.89% with HIG ineffectiveness or with incidence of 0.82% if HIG is 30% effective [2]. Although policy implementation requires continued evaluations of HIG efficacy and more accurate results, current data can be used to drive policy development. Additionally, Schaefer et al. emphasized the importance of integrating CMV education into routine prenatal care to increase awareness and reduce infection risks [13]. Specifically, Hughes et al. suggest using in-office videos and brief motivational counseling as effective tools to disseminate prevention information [14].

Several studies highlight the importance of targeted messaging and behavior-focused interventions. Levis et al. advocated for audience testing and gain-framed messages that emphasize the benefits of CMV prevention strategies in achieving healthy baby outcomes [16]. Moreover, Thackeray et al. emphasized the need for messaging that enhances perceived behavioral control and response efficacy, focusing on risky behaviors such as kissing and sharing saliva with young children [19]. Further, Price et al. called for further research into the effectiveness of health education materials in influencing behavior changes and reducing CMV risk [17]. A common theme across these studies is the critical role of education in increasing awareness and reducing CMV transmission risks. From in-clinic tools like videos and counseling to gain-framed messages and behavior-based interventions, these strategies are essential for reaching women at risk. The integration of CMV education into routine prenatal care is widely recommended, with a focus on promoting hygiene practices and reducing high-risk behaviors. Additionally, multiple studies emphasize the need for further research to refine educational tools, explore their long-term impact, and determine cost-effectiveness thresholds. All in all, the recommendations show the impact of education and behavior modification in the prevention of CMV.

4. Discussion

This review seeks to investigate the various CMV interventions and screening policies in the U.S., identify effective strategies to enhance CMV screening rates, and offer future recommendations for improvements in U.S. healthcare settings. The insights gained from this review aim to provide recommendations and guide future implementation strategies and broader dissemination of evidence-based screening and educational initiatives to ultimately enhance maternal and infant health outcomes and prevent CMV infections.

Significant findings from this review illustrate a modest increase in behavioral compliance scores associated with video and motivational interviewing during the prenatal care setting, alongside changes in risk perception related to CMV severity, susceptibility, self-efficacy, and perceived norms [15]. Participants preferred prevention strategies that included risk reduction messages and stories about CMV [16]. Additionally, health education materials were well received by pregnant women as they demonstrated an improvement in participants’ knowledge, awareness, and motivation to engage in CMV prevention behaviors, such as an increased use of recommended hygiene practices [17,18,19]. Despite these findings, there continues to be a lack of representation for diverse communities, and there is a need for more culturally tailored educational and screening interventions for CMV that consider the growing diversity of the U.S. pregnant population for successful implementation [20]. For instance, Hussein et al. noted that less than 45% of the Minnesota Somali-American community was aware of cCMV [21]. Once collaboration with existing community organizations was established, this allowed for the delivery of culturally tailored education sessions to pregnant women, which in turn contributed to an overall increased awareness of cCMV in the Somali community and thus aided in increasing acceptance of cCMV screening [21]. Similar interventions were also successful in preventing other acquired high-risk infectious diseases during pregnancy [22]. Further, it was found that HIV knowledge among pregnant Latinas in rural South Carolina was suboptimal, with only 24% of women having a high understanding of the risk of perinatal HIV transmission [22]. In Nigeria, a culturally adapted, community-based program, Healthy Beginning Initiative, was initiated to work with hard-to-reach, resource-limited communities that have pregnant women to provide HIV health education and on-site laboratory testing to increase HIV screening [23]. The study reported that 92% of the women who attended the Health Beginning Initiative intervention decided to have HIV testing during their pregnancy [23]. Ensuring culturally appropriate educational interventions, multilingual and multicultural services, as well as including educated prenatal healthcare providers can help vulnerable women become better informed of high-risk infections during their pregnancy [20,21,22,23].

Included articles highlight the importance of both prevention and screening policies in addressing maternal and child health. Albright et al. demonstrated that universal CMV screening can be cost-effective, especially when considering CMV’s primary incidence and the effectiveness of early treatment [14]. Similarly, Schaefer et al. emphasized that primary prevention efforts, such as behavior modification and prenatal education, effectively reduce risky behaviors associated with CMV transmission [18]. Comparatively, established screening and prevention programs for other infectious diseases like Gonorrhea, Chlamydia, HIV, hepatitis B, and syphilis have significantly reduced maternal and neonatal morbidity and mortality, emphasizing the potential for CMV policies to achieve similar outcomes. Unlike such infections, however, CMV lacks formal prenatal screening recommendations from authoritative bodies such as the ACOG or the CDC [24]. ACOG’s current stance against CMV prenatal screening cites insufficient evidence regarding effective treatments as a primary barrier [24]. The limited availability of screening guidelines for CMV highlights a critical gap in prenatal care, underscoring the urgent need for sustained funding and research to address this issue. Currently, institutions do not recommend routine prenatal CMV screenings due to the lack of known efficacious treatment options, and, as a result, the criteria necessary to justify universal screening are not yet met [25]. This gap persists despite evidence pointing to the significant healthcare, economic, and social burdens associated with cCMV [26,27]. For infections like Gonorrhea or Chlamydia, screening is justified because effective treatments and prevention measures, such as antibiotics, are available to mitigate maternal–fetal transmission [28,29]. To this day, CMV presents a unique challenge due to the absence of such definitive interventions, raising questions about the utility of universal screening.

The substantial economic, social, and healthcare burdens associated with cCMV highlight the importance of prevention-focused policies. Albright et al. demonstrated that prenatal CMV screening could reduce the economic burden on families by facilitating earlier diagnosis and intervention [14]. The CDC reports that approximately 1 in 200 infants is born with cCMV, and about 1 in 5 of these infants will experience significant health issues, including developmental delays or hearing loss [30]. Financially, cCMV adds an average of $58,806 in healthcare costs during the first year of life—a figure nearly seven times higher than that for healthy infants [26]. These statistics underscore the urgency of implementing preventive measures and policies similar to those present for other infectious diseases. Preventive strategies for CMV could mirror existing recommendations for other infection risks during pregnancy, such as avoiding cat litter to prevent toxoplasmosis or abstaining from alcohol and drugs [31,32]. Educating pregnant women on simple behavioral changes, like frequent handwashing and avoiding contact with saliva from young children, could significantly reduce CMV transmission rates [15]. Given the success of policies for other TORCHES infections in improving maternal and child health, expanding CMV prevention and screening guidelines could have comparable benefits [28,29,32]. However, major barriers to the design, dissemination, implementation, and sustainability of evidence-based CMV screening interventions and policy efforts persist, including a lack of robust evidence supporting the efficacy of proposed treatments, such as hyperimmune globulin (HIG), as well as significant cultural and healthcare-based obstacles [14,18,19]. Cultural practices and beliefs often contradict recommended behavioral prevention strategies, such as avoiding contact with young children’s saliva or practicing enhanced hygiene measures [19]. Additionally, healthcare providers frequently cite time constraints as a significant challenge, limiting their ability to educate and guide patients effectively on CMV prevention [18].

To address these barriers, solutions must focus on enhancing research efforts, increasing provider training, and integrating education into routine prenatal care. Expanding funding for studies on the efficacy of HIG and antiviral treatments is critical to establish evidence-based interventions [33]. Increased funding is essential to advance research into potential treatments, such as hyperimmune globulin (HIG) or antivirals, which may reduce the burden of cCMV infection [33]. Such financial support could accelerate the development of evidence-based interventions, paving the way for comprehensive screening guidelines [34,35]. Without this investment, progress in CMV prevention and early detection will remain stagnant. The importance of research cannot be overstated, as it plays a pivotal role in informing policy decisions and bridging the gap in CMV screening rates [4,35]. To ensure better maternal and child health outcomes, prioritizing financial resources for CMV research and guideline development must be a public health imperative. A cost–benefit analysis of CMV screening in the United States suggests that maternal and newborn screenings are often the most cost-effective approach, particularly for preventing maternal–fetal transmission of CMV infections and associated increased risk of hearing loss [36]. Moreover, culturally tailored educational campaigns could improve community acceptance of behavioral prevention strategies, while leveraging technology, such as telehealth and digital resources, may support providers in delivering consistent patient education [18,19]. This is particularly important among high-risk mothers with diverse cultural backgrounds and lower educational levels since compliance to recommended screening guidelines becomes even more challenging due to specific barriers experienced by this vulnerable group [18,19]. Additionally, more research is needed to explore culturally relevant and unified guidelines for CMV screening in pregnant women globally. In 2023, a cCMV guidelines group was convened under the patronage of the European Society of Clinical Virology to evaluate the quality of evidence on cCMV screening. Resulting recommendations address management of cCMV, spanning from prevention to postnatal care [37]. They also strive to refine personalized postnatal care based on risk assessment to improve reach of interventions in affected families. Similar studies should be conducted in the US to refine and disseminate evidence-based screening guidelines for cCMV [37]. Finally, policy changes incentivizing CMV education during prenatal visits could help ensure the sustainability of prevention and screening efforts, ultimately bridging gaps identified in the current system [18,19].

5. Limitations

Despite the importance of the findings of our study, offering guidance for applying and expanding screening and educational initiatives to enhance maternal and infant health and prevent CMV infection, several limitations should be considered. First, although an extensive literature search was conducted across three databases, only six articles met the inclusion criteria. Second, the review was confined to these three databases and did not include manual searches of journals or published scientific reports. Third, due to the limited scope of the review, a quality assessment of the included studies was not performed. However, although limited in scope, the findings are intended to guide the future dissemination and implementation of innovative, evidence-based interventions to increase the reach of CMV screening for U.S. pregnant women, especially those in vulnerable groups, to improve overall CMV screening rates and reduce maternal and neonatal CMV infections. There is a need for additional evidence-based interventions to fill gaps in the literature and address this women’s rights issue by integrating educational tools that consider the cultural and social factors of the targeted population.

6. Conclusions

This review emphasizes the need for enhanced CMV screening and prevention strategies in pregnant women in the U.S. Many effective interventions, such as motivational interviewing, risk reduction messages, narratives about CMV, and culturally tailored educational resources, have demonstrated the potential to improve awareness and compliance among pregnant women. However, challenges for CMV prevention and screening continue due to the disparities in community representation, along with the absence of strong evidence-based treatment options and recommended CMV screening guidelines. In order to address those obstacles, there needs to be an increase in research funding and provider training on CMV prenatal education and early intervention, along with continuous mobilization efforts to call for the creation of comprehensive screening guidelines, and the incorporation of culturally directed educational initiatives into standard pre- and perinatal care. Such interventions will help close gaps in maternal healthcare services, facilitate early detection, and ultimately enhance maternal and infant health outcomes by reducing the prevalence and impact of CMV infections.