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PLoS Med. 2017 Aug 8;14(8):e1002373. doi: 10.1371/journal.pmed.1002373. eCollection 2017 Aug.

Malaria, malnutrition, and birthweight: A meta-analysis using individual participant data.

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Department of Epidemiology, UNC-Chapel Hill, Chapel Hill, North Carolina, United States of America.
Department of Obstetrics and Gynaecology, Edinburgh Royal Infirmary, Edinburgh, United Kingdom.
Department of Medicine at the Doherty Institute, The University of Melbourne, Parkville, Victoria, Australia.
UMR216-MERIT, French National Research Institute for Sustainable Development (IRD), Paris Descartes University, Paris, France.
Unite de Recherche Clinique de Nanoro, Institut de Recherche en Sciences de la Santé-DRO, Bobo-Dioulasso, Burkina Faso.
Departement de Recherche Clinique, Centre Muraz, Bobo-Dioulasso, Burkina Faso.
Medical Research Council Unit, The Gambia; London School of Hygiene and Tropical Medicine, London, United Kingdom.
Worldwide Epidemiology, GlaxoSmithKline, Uxbridge, United Kingdom.
Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana.
Department of Nutrition, University of California, Davis, California, United States of America.
Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
Kenya Medical Research Institute (KEMRI)/ Centre for Global Health Research, Kisumu, Kenya.
Malaria and Neglected Tropical Diseases, Center for Malaria Control and Elimination, PATH, Seattle, Washington, United States of America.
Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.
School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi.
Center for Child Health Research University of Tampere School of Medicine and Tampere University Hospital, Tampere, Finland.
Walter and Eliza Hall Institute, Parkville, Victoria, Australia.
Institute for Glycomics, Griffith University, Gold Coast, Queensland, Australia.
Centre for Medical Parasitology, Depart. Of Immunology and Microbiology, Faculty of Health Science, University of Copenhagen, Copenhagen, Denmark.
National Institute for Medical Research, Tanga Centre, Tanga, Tanzania.
Department of Pediatrics, Division of Neonatal-Perinatal Medicine, School of Medicine, UNC-Chapel Hill, Chapel Hill, North Carolina, United States of America.
Department of Nutrition, UNC-Chapel Hill, Chapel Hill, North Carolina, United States of America.



Four studies previously indicated that the effect of malaria infection during pregnancy on the risk of low birthweight (LBW; <2,500 g) may depend upon maternal nutritional status. We investigated this dependence further using a large, diverse study population.


We evaluated the interaction between maternal malaria infection and maternal anthropometric status on the risk of LBW using pooled data from 14,633 pregnancies from 13 studies (6 cohort studies and 7 randomized controlled trials) conducted in Africa and the Western Pacific from 1996-2015. Studies were identified by the Maternal Malaria and Malnutrition (M3) initiative using a convenience sampling approach and were eligible for pooling given adequate ethical approval and availability of essential variables. Study-specific adjusted effect estimates were calculated using inverse probability of treatment-weighted linear and log-binomial regression models and pooled using a random-effects model. The adjusted risk of delivering a baby with LBW was 8.8% among women with malaria infection at antenatal enrollment compared to 7.7% among uninfected women (adjusted risk ratio [aRR] 1.14 [95% confidence interval (CI): 0.91, 1.42]; N = 13,613), 10.5% among women with malaria infection at delivery compared to 7.9% among uninfected women (aRR 1.32 [95% CI: 1.08, 1.62]; N = 11,826), and 15.3% among women with low mid-upper arm circumference (MUAC <23 cm) at enrollment compared to 9.5% among women with MUAC ≥ 23 cm (aRR 1.60 [95% CI: 1.36, 1.87]; N = 9,008). The risk of delivering a baby with LBW was 17.8% among women with both malaria infection and low MUAC at enrollment compared to 8.4% among uninfected women with MUAC ≥ 23 cm (joint aRR 2.13 [95% CI: 1.21, 3.73]; N = 8,152). There was no evidence of synergism (i.e., excess risk due to interaction) between malaria infection and MUAC on the multiplicative (p = 0.5) or additive scale (p = 0.9). Results were similar using body mass index (BMI) as an anthropometric indicator of nutritional status. Meta-regression results indicated that there may be multiplicative interaction between malaria infection at enrollment and low MUAC within studies conducted in Africa; however, this finding was not consistent on the additive scale, when accounting for multiple comparisons, or when using other definitions of malaria and malnutrition. The major limitations of the study included availability of only 2 cross-sectional measurements of malaria and the limited availability of ultrasound-based pregnancy dating to assess impacts on preterm birth and fetal growth in all studies.


Pregnant women with malnutrition and malaria infection are at increased risk of LBW compared to women with only 1 risk factor or none, but malaria and malnutrition do not act synergistically.

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