Six hundred thousand women die each year in pregnancy and childbirth, and nearly all of these deaths occur in the developing world. The proportion of maternal deaths directly due to anaemia is 8% to 16%, and anaemia contributes significantly to maternal mortality from infection, haemorrhage, eclampsia, abortion and obstructed labour. Despite international efforts from governmental and nongovernmental agencies, the prevalence of anaemia in the developing world has not changed in the past decade, mainly due to difficulties with prophylactic therapy as regards distribution and compliance. It was this which prompted N. R. van den Broek and colleagues (pages 445–451) to conduct their observational study of the prevalence of anaemia in pregnancy in urban and rural populations in southern Malawi; a second purpose was to identify groups of women who were at especially high risk of anaemia and who could be targeted for prophylaxis. The prevalence of anaemia was 57% in the urban and 72% in the rural populations, and of severe anaemia 4% in both populations, frequencies which are typical in sub-Saharan Africa. In the developed world the prevalence of anaemia in pregnancy is less than 10%, and severe anaemia is practically unknown. The authors carried out a multiple regression analysis and found that primiparity and the wet season were independent risk factors for anaemia. The common factor is malaria which is more common in the wet season and to which primiparae are specially susceptible. However, by targeting primiparae only for prophylactic therapy about two-thirds of susceptible women would be missed, and so the authors advocate universal prophylactic therapy with iron, folic acid and the anti-malarial drugs.

In an accompanying commentary R. J. Guidotti (pages 437–438) continues this theme, and suggests that prophylaxis should be extended to antihelminthic therapy to eradicate hookworm infection which afflicts 44 million pregnant women each year. Prophylactic therapy should also include multivitamin tablets since pregnant women may have other nutritional deficiencies. However, problems of distribution and compliance remain, and successful prevention of nutritional anaemia in pregnancy may only come about with changes in growing food. A policy of fortification of food with iron and vitamins has been successful in South America and the Caribbean. Genetically modified foods may become very important in the prevention of anaemia, for it is possible to alter grain to reduce its content of phytate and increase its content of cysteine and so improve the absorption of iron from the intestine, and to modify rice to produce enough beta-carotene to supply all the vitamin A required in pregnancy.