Increased serum phospholipase A2 activity in Malawian children with falciparum malaria.

Some clinical manifestations of severe malaria resemble those of sepsis and there may be mediators of the host response that are common to both sepsis and malaria. Phospholipase A2 (PLA2), a proinflammatory enzyme whose expression is induced by tumor necrosis factor (TNF), has been implicated in the pathogenesis of complications of the sepsis syndrome. We examined levels of circulating PLA2 in Plasmodium falciparum malaria and studied the association of PLA2 with disease severity. Plasma PLA2 and TNF were measured in 75 Malawian children with P. falciparum malaria. The mean (SD) plasma PLA2 activity in children with acute malaria was 53,804 (37,256) units/ml as compared with 424 (349) units/ml in 34 healthy controls (P < 0.00001). The mean PLA2 activity in 45 convalescent patients was 2,546 (7,372) units/ml (P < 0.00001). In 48 patients with pretreatment PLA2 activity less than 60,000 units/ml, mortality was 8.3%, while in 27 patients with pretreatment PLA2 levels greater than 60,000 units/ml, mortality was 33.3% (P = 0.008). There were significant correlations between PLA2 and TNF (r = 0.471, P < 0.01), density of parasitemia (r = 0.443, P < 0.0001) and a decrease in hematocrit (r = 0.352, P < 0.005). These data show that P. falciparum malaria is associated with a markedly increased circulating PLA2, especially in patients with severe disease, as manifested by high parasite burden, anemia, coma, and death.

An analysis of intra-uterine growth retardation in rural Malawi.

OBJECTIVE: (1) To describe the sex-specific, birth weight distribution by gestational age of babies born in a malaria endemic, rural area with high maternal HIV prevalence; (2) to assess the contribution of maternal health, nutritional status and obstetric history on intra-uterine growth retardation (IUGR) and prematurity. METHODS: Information was collected on all women attending antenatal services in two hospitals in Chikwawa District, Malawi, and at delivery if at the hospital facilities. Newborns were weighed and gestational age was assessed through post-natal examination (modified Ballard). Sex-specific growth curves were calculated using the LMS method and compared with international reference curves. RESULTS: A total of 1423 live-born singleton babies were enrolled; 14.9% had a birth weight <2500 g, 17.3% were premature (<37 weeks) and 20.3% had IUGR. A fall-off in Malawian growth percentile values occurred between 34 and 37 weeks gestation. Significantly associated with increased IUGR risk were primiparity relative risk (RR) 1.9; 95% CI 1.4--2.6), short maternal stature (RR 1.6; 95% CI 1.0--2.4), anaemia (Hb<8 g/dl) at first antenatal visit (RR 1.6; 95% CI 1.2--2.2) and malaria at delivery (RR 1.4; 95% CI 1.0--1.9). Prematurity risk was associated with primiparity (RR 1.7; 95% CI 1.3--2.4), number of antenatal visits (RR 2.2; 95% CI 1.6--2.9) and arm circumference <23 cm (RR 1.9; 95% CI 1.4--2.5). HIV infection was not associated with IUGR or prematurity. CONCLUSION: The birth-weight-for-gestational-age, sex-specific growth curves should facilitate improved growth monitoring of newborns in African areas where low birth weight and IUGR are common. The prevention of IUGR requires improved malaria control, possibly until late in pregnancy, and reduction of anaemia.

Placental antibody transfer: influence of maternal HIV infection and placental malaria.

AIM: To determine the influence of placental malaria, maternal HIV infection, and maternal hypergammaglobulinaemia on transplacental IgG antibody transfer. METHODS: One hundred and eighty materno-neonatal pairs from a Malawian population were assessed. Cord and maternal serum samples were tested for total serum IgG antibody titres using nephelometry, and for specific IgG antibody titres to Streptococcus pneumoniae, measles, and tetanus toxoid antibodies using an enzyme linked immunosorbent assay (ELISA). RESULTS: Multiple regression analyses showed that placental malaria was associated with a decrease in placental IgG antibody transfer to S pneumoniae and measles to 82% and 81%, respectively. Maternal HIV infection was associated with a reduction in IgG antibody transfer to S pneumoniae to 79%; raised maternal total serum IgG titres were correlated with S pneumoniae and measles IgG antibody transfer reduction to 86% and 87%, respectively. No effect was seen with tetanus toxoid antibody transfer. CONCLUSION: The combined influence of placental malaria, maternal HIV infection, and maternal hypergammaglobulinaemia seems to be linked to the low transplacental antibody transfer observed in the Malawian population.

A study of the consequences of malarial infection in pregnant women and their infants.

An outline is given of a field research study to be undertaken in Malawi to investigate the pattern and consequences of malaria in pregnancy and infants. The central question to be investigated is whether babies born to anaemic mothers in malarious areas are at increased risk of developing anaemia or altered risk for morbidity from malaria or develop anaemia in the first year of life. The framework for the case control and cohort study to be undertaken is outlined.

PIP: Outlined is the protocol for field research in Malawi aimed at ascertaining whether infants born to anemic mothers in areas where malaria is prevalent are at increased risk of morbidity. Specifically, the research seeks to: 1) quantify the prevalence and pattern of anemia in infants living in areas where malaria is endemic; 2) investigate whether birth hemoglobin is associated with clinical risk in infancy; 3) measure the associations between fetal anemia, maternal iron status, and malaria in pregnancy; and 4) quantify the contribution of maternal anemia and iron status to fetal growth retardation. Anemia incidence and malaria prevalence will be assessed through a larger cohort study of infants enrolled at birth and followed for up to 18 months. Also planned is a case-control study that will compare infants born with and without fetal anemia. Odds ratios for maternal anemia, iron deficiency, and parasitemia will be computed for cases and controls to determine the relative contribution of each to fetal hemoglobin status. Finally, the risk of maternal parasitemia, iron deficiency, and anemia will be measured in low-birth-weight, growth-retarded infants and those with normal birth weights. The findings will be used to develop a strategy for anemia control among high risk mothers and infants. This is of particular concern in developing countries, where blood transfusions for anemia can lead to human immunodeficiency virus infection.

Adverse birth outcomes in a malarious area.

To determine factors associated with fetal growth, preterm delivery and stillbirth in an area of high malaria transmission in Southern Malawi, a cross-sectional study of pregnant women attending and delivering at two study hospitals was undertaken. A total of 243 (17.3%) babies were preterm and 54 (3.7%) stillborn. Intra-uterine growth retardation (IUGR) occurred in 285 (20.3%), of whom 109 (38.2%) were low birthweight and 26 (9.1%) preterm. Factors associated with IUGR were maternal short stature [adjusted odds ratio (AOR) 1.6, 95% confidence interval (CI) 1.0-2.5]; primigravidae (AOR 1.9, 95% CI 1.4-2.7); placental or peripheral malaria at delivery (AOR 1.4, 95% CI 1.0-1.9) and maternal anaemia at recruitment (Hb<8 g/dl) (AOR 1.9, 95% CI 1.3-2.7). Increasing parasite density in the placenta was associated with both IUGR (P=0.008) and prematurity (P=0.02). Factors associated with disproportionate fetal growth were maternal malnutrition [mid-upper arm circumference (MUAC)<23 cm, AOR 1.9, 95% CI 1.0-3.7] and primigravidae (AOR 1.8, 95% CI 1.0-3.1). Preterm delivery and stillbirth were associated with <5 antenatal care visits (AOR 2.2, 95% CI 1.3-3.7 and AOR 3.1, 95% CI 1.4-7.0 respectively) and stillbirth with a positive Venereal Disease Research Laboratory (VDRL) test (AOR 4.7, 95% CI 1.5-14.8). Interventions to reduce poor pregnancy outcomes must reduce the burden of malaria in pregnancy, improve antenatal care and maternal malnutrition.

Improving antenatal care for pregnant adolescents in southern Malawi.

BACKGROUND: This paper considers why antenatal care (ANC) programs for adolescents may need to be improved in areas where a high proportion of first pregnancies are to young girls. DESIGN: Descriptive data on the characteristics of 615 adolescents (aged 10-19 years) who attended for a first antenatal care visit at two rural hospitals in southern Malawi are given. For the 41.5% who came for a supervised delivery, details of their pregnancy care and delivery outcome are provided. The Chi-square test is used for determining significant differences between age and parity groups and logistic regression for an analysis of low birthweight. RESULTS: Fifty-two percent of girls were nulliparous, 24.5% were < or =16 years and 73.3% were illiterate. Prevalence of anemia, malaria and HIV infection was high. Girls who were nulliparous, illiterate, made early antenatal care visits or gave a history of stillbirth or abortion were less likely to attend for delivery. Few primiparae required an assisted vaginal delivery or cesarean section but primiparae had more adverse birth outcomes. Forty percent of primiparae <17 years gave birth to low birthweight babies as did 28.3% of multiparae. In a logistic regression (all adolescents) low birthweight was correlated with literacy (p=0.03) and number of antenatal care visits (p=0.01). CONCLUSIONS: Pregnancy morbidity and adverse birth outcomes were common in spite of antenatal care attendance. This partly reflects poor management of malaria during pregnancy. In areas like Malawi, where childbearing starts early, girls in their first pregnancy need good quality care and careful monitoring if problems are not to be perpetuated to a second pregnancy. Many girls start pregnancy with HIV and schistosomal infections which indicates the need for programs before girls become pregnant.

PIP: A descriptive study of 615 girls 10-19 years of age attending their first prenatal visit at 2 rural hospitals in southern Malawi revealed a need to improve the quality of antenatal care for this high-risk group. 52% of teens were nulliparous and 73.3% were illiterate. Most nulliparae first attended for antenatal care at 20-23 weeks of gestation, while multiparae tended to report at 24-27 weeks. The mean number of antenatal visits was high: 5.3. 26.6% of pregnant adolescents were HIV-infected, 34.4% had malaria, and 92.6% were anemic. Details of pregnancy outcome were available only for the 251 girls (41.5%) who presented for supervised delivery. Girls who were nulliparous, illiterate, made early antenatal care visits, or gave a history of stillbirth or abortion were less likely to attend for delivery. 40% of primiparae under 17 years of age and 28.3% of multiparae had a low-birth-weight infant. Logistic regression analysis indicated that low birth weight was significantly inversely associated with literacy and number of antenatal care visits. The prevalence of peripheral parasitemia was as high at delivery as at first antenatal visit, indicating that malaria control during pregnancy was not performed or was not effective. These findings indicate that, when adolescent pregnancy begins at an early age, girls in their first and second pregnancies require intensive monitoring. On the other hand, in settings such as Malawi, where many young girls are anemic and HIV-infected when they become pregnant and have infections such as schistosomiasis that cannot be treated during pregnancy, programs must be initiated to improve the health status and literacy of young girls before they reach childbearing age.

An analysis of the determinants of anaemia in pregnant women in rural Malawi--a basis for action.

Haematological data are presented on 4104 pregnant women attending the antenatal-care facilities of two hospitals in a rural area in southern Malawi. In this area, malaria transmission is perennial and there is a high prevalence of HIV infection. The local women are exposed to drought and food shortages but experience high fertility rates. Mean (S.D.) haemoglobin (Hb) concentration was significantly lower in the primigravidae [8.7 (1.60 g/dl] than in the secundigravidae [9.1 (1.5) g/dl; P < 0.0001] or multigravidae [9.2 (1.5) g/dl; P < 0.0001]. Primigravidae also experienced significantly more iron deficiency and malaria than secundi- or multi-gravidae. For all parity groups, the lowest mean Hb levels were observed between 26-30 weeks' gestation. In primigravidae peak prevalence of malaria occurred between 16-20 weeks' gestation (38.6%) and peak prevalence of moderately severe anaemia (< 8 g Hb/dl) between 26-30 weeks' (35.7%). Multigravidae showed little variation in the prevalence of anaemia, iron deficiency and malaria with gestational age. Peak prevalences of malaria were observed in April, in the post-rainy season, with values of 51.4%, 56.0% and 25.3% for primi-, secundi- and multi-gravidae, respectively. Peak prevalences of iron deficiency occurred between April and May and those of moderately severe anaemia between May and June. Mean Hb was lower in adolescent primigravidae than in any other group of pregnant women [8.6 (1.5) g/dl], including the non-adolescent primigravidae [8.9 (1.6) g/dl; P = 0.008]. Other factors significantly associated with increased risk of moderately severe anaemia in primigravidae were illiteracy and poor nutritional status (i.e. body mass index < 18.5 kg/m2 and mid-upper-arm circumference < 23 cm). After forward, step-wise, regression analysis of relative risk (RR) factors and their 95% confidence intervals (CI), variables associated with an increased risk for moderately severe anaemia were iron deficiency (RR = 4.2; CI = 3.0-6.0) and malaria parasitaemia (RR = 1.9; CI = 1.3-2.7) in primigravidae, iron deficiency (RR = 4.1; CI = 2.7-6.3) and mid-upper-arm-circumference < 23 cm (RR = 1.8; CI = 1.1-3.0) in secundigravidae, and iron deficiency in multigravidae (RR = 3.1; CI = 4.3-6.9).

Malaria in pregnancy and its consequences for the infant in rural Malawi.

Maternal malaria and anaemia, pregnancy and infant outcomes are reviewed among a cohort of mothers and their babies living in Chikwawa district, southern Malawi. Overall, 4104 women were screened at first antenatal visit and 1523 at delivery. Factors independently associated with moderately severe anaemia (MSA; < 8 g haemoglobin/dl) in primigravidae were malaria (relative risk = 1.9; 95% confidence interval = 1.6-2.3) and iron deficiency (relative risk = 4.2; 95% confidence interval = 3.5-5.0). Only iron deficiency was associated with MSA in multigravidae. After controlling for antimalarial use, parasitaemia was observed in 56.3% of the HIV-infected primigravidae and 36.5% of the non-infected (P = 0.04). The corresponding figures for multigravidae were 23.8% and 11.0%, respectively (P = 0.002). Over 33% of the infants born alive to primigravidae were of low birthweight (LBW; < 2500 g), and 23.3% of all newborns had foetal anaemia (< 12.5 g haemoglobin/dl cord blood). LBW was significantly associated in primigravidae with pre-term delivery, placental malaria and frequency of treatment with sulfadoxine-pyrimethamine (SP), and in multigravidae with pre-term delivery, adolescence, short stature and MSA. LBW was significantly reduced with a second SP treatment in primigravidae, and with iron-folate supplementation in multigravidae. Mean haemoglobin concentrations were significantly lower in the infant who had been LBW babies than in the others, and significantly associated with parity, peripheral parasitaemia at delivery and placental malaria. At 1 year post-delivery, life status was known for 364 (80.7%) of the 451 infants enrolled in the follow-up study. Independent risk factors for post-neonatal mortality were maternal HIV infection, LBW, and iron deficiency at delivery. This study identifies priorities for improving the health of pregnant women and their babies in this rural area of Malawi.

An evaluation of the effects of intermittent sulfadoxine-pyrimethamine treatment in pregnancy on parasite clearance and risk of low birthweight in rural Malawi.

The prevalence of infection with malarial parasites and the incidence of anaemia and delivery of infants with low birthweight (LBW) were investigated in 575 Malawian mothers who received one, two or three doses of sulfadoxine-pyrimethamine (SP) during pregnancy. All the subjects were enrolled at their first antenatal visit and all delivered at hospital. The prevalence of Plasmodium falciparum infection at first antenatal visit was 35.3% in primigravidae and 13.6% in multigravidae (P < 0.001). Mean haemoglobin concentration was significantly lower in primigravidae than in multigravidae (8.8 v. 9.5 g/dl; P < 0.001). Of the 233 women tested for HIV infection, 18.8% of the primigravidae and 23.7% of the multigravidae were seropositive. At delivery, there was no significant difference in parasite prevalence in peripheral or placental blood between women who had received one or two antenatal doses of SP. The multigravidae who had received two doses of SP had higher mean haemoglobin concentrations than those who had received just one (P = 0.009) [this difference was not seen in the primigravidae (P = 0.92)]. However, linear regression analysis indicated that the haematinic supplements given to the subjects contributed more to this increase in haemoglobin concentration than the SP. The mean birthweights were higher, and incidence of LBW lower in babies born to primi-and multi-gravidae who had received two or three doses of SP treatment than those seen in babies born to women who had had just one dose (P < 0.03 for each). The odds ratio for LBW in primigravidae compared with multigravidae decreased from 3.2 to 1.0 as the number of SP doses increased from one to three. The benefit of three doses (compared with none) was equivalent to the population-attributable risk of LBW in primigravidae being reduced from 34.6% to 0%. Subjects who were seropositive for HIV were twice as likely to give birth to LBW babies as the other subjects. The use of SP was not associated with maternal side-effects or perinatal complications. The present results indicate that multiple doses of SP taken during pregnancy will lead to a highly significant reduction in the incidence of LBW in infants born to primigravidae, even if the women have HIV infections. This reduction is observable even when parasite prevalence at delivery is high because of re-infections in late pregnancy; reduction in parasite prevalence earlier in pregnancy, as the result of SP treatment, leads to improved foetal growth.

PIP: The effect of antimalarial treatment followed by chemoprophylaxis during pregnancy on low birth weight (LBW) and anemia was investigated in a study conducted in Chikwawa District Hospital, Malawi, in 1993-94. The 575 women from this malaria-endemic community who were enrolled at their first prenatal visit and delivered at the Chikwawa Hospital were included in the data analysis; 24.3% were primigravidae. At enrollment, the prevalence of Plasmodium falciparum infection was 35.3% in primigravidae and 13.6% in multigravidae. At delivery, there was no significant difference in parasite prevalence between women who had received 1 or 2 antenatal doses of sulfadoxine-pyrimethamine (SP). Multigravidae--but not primigravidae--who received 2 SP doses had higher mean hemoglobin levels than those who received just 1 dose; however, linear regression analysis indicated that hematinic supplements contributed more to this increase than SP. The mean birth weights of infants born to primi- and multigravidae who received 2 or more doses of SP were significantly higher than those of infants whose mothers received only 1 dose. The odds ratio for LBW in primigravidae compared with multigravidae decreased from 3.2 to 1.0 as the number of SP doses increased from 1 to 3. The benefit of 3 doses compared with no treatment was equivalent to the population-attributable risk of LBW in primigravidae being reduced from 34.6% to 0. HIV-positive women (18.8% of primigravidae and 23.7% of multigravidae) were twice as likely to have LBW infants than HIV-negative women. The reduction in LBW deliveries was significant even when parasite prevalence at delivery was high as a result of reinfection in late pregnancy.

Risk factors for fetal anaemia in a malarious area of Malawi.

The prevalence of infants born with low cord haemoglobin (fetal anaemia) is high in areas where malaria and iron deficiency anaemia in pregnancy are common. The objective of the present study was to determine risk factors for fetal anaemia in an area of high malaria transmission in southern Malawi. A case control study was undertaken with fetal anaemia defined as cord haemoglobin (Hb) < 12.5 g/dl. Between March 1993 and July 1994, pregnant women attending the study hospitals for the first time in that pregnancy were enrolled. Data on socio-economic status, anthropometry, previous obstetric history and current pregnancy were collected. Malaria parasitaemia, Hb levels and iron status were measured in maternal blood at recruitment and delivery and in umbilical venous blood. Fetal anaemia occurred in 23.4% of babies. Mean (SD) cord Hb was 13.6 g/dl (1.83). Factors associated with fetal anaemia were: birth in the rainy season [adjusted odds ratio (AOR) 2.33, 95% CI 1.73-3.14], pre-term delivery (AOR 1.60, 1.03-2.49), infant Hb < 14 g/dl at 24 hours (AOR 2.35, 1.20-4.59), maternal Hb at delivery < 8 g/dl (AOR 1.61, 1.10-2.42) or <11 g/dl (AOR 1.60, 1.10-2.31). A higher prevalence of fetal anaemia occurred with increasing peripheral Plasmodium falciparum parasite density (p=0.03) and geometric mean placental parasite densities were higher in babies with fetal anaemia than in those without (3331 vs 2152 parasites/microl, p=0.07). Interventions should aim to reduce fetal anaemia by improving malaria and anaemia control in pregnancy and by addressing the determinants of pre-term delivery.

Increased prevalence of malaria in HIV-infected pregnant women and its implications for malaria control.

OBJECTIVES: To examine in pregnant women the relationship between HIV infection and malaria prevalence and to determine, in relation to HIV infection, the effectiveness of sulphadoxine-pyrimethamine in clearing P. falciparum infection. METHOD: Descriptive cross-sectional analysis of P. falciparum prevalence in pregnant women at first antenatal visit and of women at delivery who had received two sulphadoxine-pyrimethamine treatments for malaria. HIV status was assessed in 621 women who attended for antenatal care and for delivery at two rural hospitals in southern Malawi in 1993-94. Information was collected on maternal age, parity and gestational age. Prevalence of P. falciparum was measured at first antenatal visit and delivery. Women were given two routine treatment doses of sulphadoxine-pyrimethamine (SP), at first antenatal visit and between 28 and 34 weeks gestation, conforming to Malawi government policy on antimalarial control during pregnancy. RESULTS: Prevalence of HIV infection was 25.6% and all infections were HIV type-1. In primigravidae malaria prevalence at recruitment was 56.3% in HIV-infected and 36.5% in HIV-uninfected women (P=0.04). The corresponding figures for multigravidae were 23.8% and 11.0%, respectively (P<0.01). HIV-infected primigravidae had increased malaria prevalence at all gestational ages. Peak parasite prevalence occurred earlier in gestation in HIV-infected primigravidae (16-19 weeks if HIV-infected; 20-23 weeks if HIV-uninfected). The relative risk for parasitaemia in HIV-infected compared to HIV-uninfected women was significantly increased in three of five parity groups, including the two highest ones (parity>3), indicating parity-specific immunity to malaria was impaired. Malaria prevalence at delivery remained high in HIV-infected women despite prior routine treatment with sulphadoxine-pyrimethamine in pregnancy There was no significant difference in parasite prevalence at delivery between women who did or did not use sulphadoxine-pyrimethamine. CONCLUSIONS: HIV infection is associated with a significant increase in malaria prevalence in pregnant women of all parities with the effect apparent from early in gestation. Two treatment doses of sulphadoxine-pyrimethamine were inadequate to clear parasitaemia in many women by the time of delivery and this occurred independently of HIV status and despite high sensitivity to SP in this area. There is a need to undertake longitudinal studies to determine the incidence of P. falciparum infection in HIV-infected and uninfected pregnant women and to reassess the frequency and timing of sulphadoxine-pyrimethamine treatment doses in these women. Late pregnancy re-infections with P. falciparum probably explain the high parasite prevalence at delivery following sulphadoxine-pyrimethamine treatment at 28-34 weeks gestation.

The consequences of malaria infection in pregnant women and their infants.

Preliminary results are presented from this study which indicate that 84.8% of pregnant women present at first antenatal visit with anemia (Hb 11g/dl) an 8.7% of their infants (n = 230) have a hemoglobin at birth below 14g/dl. There is an association between pregnancy anemia and malaria. A case control study in pregnant women and an infant cohort study to 18 months of age, are employed to study the cause and effects of anemia and malaria on women and their infants health.

Haematological profiles of the people of rural southern Malawi: an overview.

An integrative review of the results of two published and two unpublished studies of anaemia in children, adolescent females, pregnant women and adults living in southern Malawi is presented. Anaemia was universally present in all age-groups, with the higher prevalences in infants (100%) and adolescent primigravidae (93.8%). Nutritional deficits of iron and vitamin A were major contributory factors but chronic malarial haemolysis also significantly contributed to the anaemia. Among boys, anaemia was more common among those with glucose-6-phosphate-dehydrogenase (G6PD) deficiency than in those without this deficiency (P<0.002). This enzymopathy, which occurred in 23.5% [95% confidence interval (CI)=16.7%-30.1%] of the male and 30% (CI=17.3%-42.7%) of the female infants examined, was also associated with neonatal jaundice. The overall prevalences of the-alpha(3.7)/alphaalpha and -alpha(3.7)/-alpha(3.7) thalassaemia genotypes were estimated at 41.0% (CI=28.3%-53.7%) and 8.7% (CI=1.5%-15.9%), respectively. Haemoglobin AS was present in 18.1% (CI=12.8%-23.4%) of the infants and haemoglobin SS in 2.5% (CI=1.4%-3.6%). As the prevalence of infection with Plasmodium falciparum was significantly higher in infants with haemoglobin AS than in those with AA (21.4% v. 6.7%; P<0.001), an increased risk of early-onset moderate parasitaemias in young infants probably stimulates the development of immunity, protecting older heterozygotes from severe malarial infection. Innovative community approaches are required to break the cycle of ill health that anaemia supports in those living in rural areas of southern Malawi. Interventions in adolescent girls could be of particular importance, as they could break the cycle in both pregnant women and their infants.

The consequences of malaria infection in pregnant women and their infants

Preliminary results are presented from this study which indicate that 84.8 of pregnant women present at first antenatal visit with anemia (Hb 11g/dl) an 8.7 of their infants (n = 230) have a hemoglobin at birth below 14g/dl. There is an association between pregnancy anemia and malaria. A case control study in pregnant women and an infant cohort study to 18 months of age, are employed to study the cause and effects of anemia and malaria on women and their infants health.