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The influence of haemoglobin genotype on the response to iron supplementation was studied in a randomized, double blind, placebo-controlled trial involving 497 multigravid pregnant women from a rural area of The Gambia. Women were randomly allocated to receive either oral iron (60mg elemental iron per day) or placebo. At 36 weeks of pregnancy, women who had received oral iron during pregnancy had higher mean haemoglobin, packed cell volume, plasma iron and ferritin levels than did women who received placebo. Iron supplementation of pregnant women with the AA haemoglobin genotype also resulted in increases in the packed cell volume (PCV) and haemoglobin level measured after delivery, and in the birth weight of the infant. However, in AS women PCV and haemoglobin level at delivery were lower in the supplemented group and supplementation was also associated with reduced birth weights. In malaria endemic areas, pregnant women with the haemoglobin genotype AS may not benefit from iron supplementation during pregnancy.

The harmful effects of malaria are most pronounced during first pregnancies and chemoprophylaxis is most effective when given at this time. However, restriction of chemoprophylaxis to first pregnancies might lead to enhanced susceptibility to malaria during second pregnancies. We have investigated this possibility by studying the outcome of second pregnancies in 165 Gambian women who had received either malaria chemoprophylaxis with Maloprim or placebo during their first pregnancy. Many of these primigravidae did not present until the third trimester of pregnancy so that some are likely to have experienced a malaria infection before they started medication. The prevalence of malaria infection of the blood and of the placenta during second pregnancies was similar in women who had received chemoprophylaxis during their first pregnancy and in those who had not, and the mean birth weights of babies born to women in each group were almost identical. Thus, in areas where the epidemiology of malaria is similar to that of The Gambia and where most women present relatively late in pregnancy, it may be possible to restrict malaria chemoprophylaxis to first pregnancies with consequent savings in cost and a reduction in drug pressure on Plasmodium falciparum.

A randomized, double-blind, placebo-controlled community-based trial of oral iron supplementation (200 mg ferrous sulphate daily) administered to multigravid pregnant women by traditional birth attendants (TBAs) was carried out in a rural area of The Gambia. Iron supplementation led to a significant reduction in the prevalence of anaemia and of iron deficiency. Iron supplementation was not accompanied by increased susceptibility to malaria infection; there was no difference in the prevalence and severity of peripheral blood or placental malaria infection between the 2 groups of women. The birth weight of children born to women who received iron prophylaxis was increased by an average of 56 g. It is concluded that oral iron prophylaxis can be successfully delivered through TBAs integrated into a primary health care programme. This simple intervention can produce significant beneficial effects on the health of the mother without inducing increased susceptibility to malaria and has the potential for reducing perinatal mortality by increasing birth weight.