BackgroundDespite twinning being common in Africa, few prospective twin studies have been conducted. We studied twinning rate, perinatal mortality and the clinical characteristics of newborn twins in urban Guinea-Bissau.MethodsThe study was conducted at the Bandim Health Project (BHP), a health and demographic surveillance site in Bissau, the capital of Guinea-Bissau. The cohort included all newborn twins delivered at the National Hospital Simão Mendes and in the BHP study area during the period September 2009 to August 2011 as well as singleton controls from the BHP study area. Data regarding obstetric history and pregnancy were collected at the hospital. Live children were examined clinically. For a subset of twin pairs zygosity was established by using genetic markers.ResultsOut of the 5262 births from mothers included in the BHP study area, 94 were twin births, i.e. a community twinning rate of 18/1000. The monozygotic rate was 3.4/1000. Perinatal mortality among twins vs. singletons was 218/1000 vs. 80/1000 (RR = 2.71, 95% CI: 1.93-3.80). Among the 13783 hospital births 388 were twin births (28/1000). The hospital perinatal twin mortality was 237/1000.Birth weight < 2000g (RR = 4.24, CI: 2.39-7.51) and caesarean section (RR = 1.78, CI: 1.06-2.99) were significant risk factors for perinatal twin mortality. Male sex (RR = 1.38, CI: 0.97-1.96), unawareness of twin pregnancy (RR = 1.64, CI: 0.97-2.78) and high blood pressure during pregnancy (RR = 1.77, CI: 0.88-3.57) were borderline non-significant. Sixty-five percent (245/375) of the mothers who delivered at the hospital were unaware of their twin pregnancy.ConclusionsTwins had a very high perinatal mortality, three-fold higher than singletons. A birth weight < 2000g was the strongest risk factor for perinatal death, and unrecognized twin pregnancy was common. Urgent interventions are needed to lower perinatal twin mortality in Guinea-Bissau.

BackgroundThe World Health Organization recommends HIV testing is included in routine screening tests for all pregnant women in order to prevent mother-to-child-transmission of HIV and reduce maternal morbidity and mortality.ObjectivesTo assess the proportion of women approached and tested for HIV at delivery and factors associated with non-testing at the maternity ward of the Simão Mendes National Hospital (HNSM) in Bissau, Guinea-Bissau.MethodsWe conducted a retrospective cross-sectional study among women presenting for delivery from June 2008 until May 2013. During the study period, national policy included opt-out HIV-testing at delivery. Modified Poisson regression models were used to examine the association of maternal characteristics with HIV testing. Time trends were determined using Pearson’s χ2 test.ResultsSeventy-seven percent (24,217/31,443) of women presenting for delivery were counselled regarding PMTCT, of whom 99.6% (24,107/24,217) proceeded with HIV testing. The provision of opt-out HIV testing at labour increased from 38.1% (1,514/3973) in 2008 to 95.7% (2,021/2,113) in 2013, p<0.001. There were four distinct periods (two or more consecutive calendar months) when less than 50% of women delivering at HNSM were tested. Periods of political instability were significantly associated with not testing for HIV (adjusted prevalence ratio [APR] 1.79; 95% CI 1.73–1.84), as was a lower educational status (APR 1.05; 95% CI 1.00–1.10), admission during evenings/nights (APR 1.05; 95% CI 1.01–1.09) and on Sundays (APR 1.14; 95% CI 1.07–1.22) and Mondays (APR 1.12; 95% CI 1.05–1.19).ConclusionsRapid scale-up of PMTCT HIV testing services and high testing coverage was possible in this resource-limited setting but suffered from regular interruptions, most likely because of test stock-outs. Establishing proper stock management systems and back-up plans for periods of political instability is required to ensure the maintenance of health system core functions and increase health system resilience.

Twins traditionally retain a special status in many African societies. In Guinea-Bissau, twins are often well regarded yet still suffer from a very high mortality, especially in the perinatal and infant period. At the Bandim Health Project, a health and demographic surveillance site, we have recently established one of the first twin registries in Sub-Saharan Africa. Our short-term aim is to describe twin mortality and morbidity in order to design appropriate health interventions. Our long-term goal is a large-scale database to explore the pathogenesis of prevalent diseases; for example, diabetes mellitus, metabolic syndrome, and infectious diseases such as HIV, tuberculosis, and malaria. A major focus area is also the etiology of low birth weight and how epigenetic processes might modulate the consequences of low birth weight in Sub-Saharan Africa. For this, monozygotic twin studies represent a powerful tool. Though twin studies have been carried out by the Bandim Health Project for more than 30 years, the renewed registry described here was officially established in 2009 and includes both a cohort of newborn twins and a cohort of young and adult twins. Currently more than 1,500 twins are being followed in the two cohorts combined. We believe that the registry holds exciting possibilities and will encourage the establishment of further twin registries across the region.

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