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The Cochrane systematic review assessed drugs given to prevent malaria infection and its consequences in pregnant women living in malarial areas. All 14 trials included in the review except Nosten 94 trial conducted in Thailand (1), were from sub-Saharan Africa, where rates of parasitaemia during pregnancy are generally high. The results are presented in three broad categories:

a) Drug prevention versus no prevention in women of all parity groups

Maternal

There was a statistically significant reduction in placental malaria between women who had prophylaxis compared with no prophylaxis (Three trials, Relative Risk [RR]: 0.34; 95% Confidence interval [CI]: 0.26 > 0.45). Although all three trials showed benefit, there was heterogeneity with regard to the level of benefit. Other maternal outcomes were reported in single trials and overall there was scanty evidence.

Newborn

Four studies reported mean birthweight. There was no statistically significant difference between drug prevention and no prevention. Similarly, there were no significant differences in perinatal death reported in four studies involving 2890 patients.

b) Drug prevention versus no prevention in women of low parity

Maternal

Drug prevention was associated with clinically and statistically significant reduction in the incidence of severe antenatal anaemia compared with no prevention in women of low parity (RR: 0.62; 95% CI: 0.50 to 0.78). This comparison was reported by four studies involving 3809 women. Placental malaria was reported in five studies. There was a trend towards protection by drug prevention but there was inconsistency between the trials reviewed.

Newborn

Eight trials involving 2245 women reported mean birthweight. Drug prevention was associated with clinical and statistically significant higher mean birthweight (Weighted mean difference [WMD]:122.62g; 95% CI: 81.49 to 163.74g). Accordingly, drug prevention also reduced the incidence of low birthweight. This difference was clinically and statistically significant (RR: 0.55; 95% CI: 0.43 to 0.70).

c) Any antimalarial (except chloroquine) compared with chloroquine

Only two studies with very few patients compared either sulfadoxine-pyrimethamine or proguanil with chloroquine. The small numbers do not permit definitive conclusions.

The methodology of the review is sufficiently rigorous. All adequately controlled trials have been included and appropriately analysed. The reviewers have made adequate efforts to contact investigators in this field.

The full RHL commentary also includes sections on: