Background. While active maternal tobacco smoking has well established adverse perinatal outcomes, the effects of passive maternal smoking, also called environmental tobacco exposure (ETS), are less well studied and less consistent. Objective: To determine to the effect of ETS on perinatal outcomes. Search strategy. Medline, EMBASE and reference lists were searched. Selection criteria. Studies comparing ETS-exposed pregnant women with those unexposed which adequately addressed active maternal smoking. Data collection and analysis. Two reviewers independently assessed titles, abstracts, full studies, extracted data and assessed quality. Dichotomous data were pooled using odds ratios (OR) and continuous data with weighted mean differences (WMD) using a random effects model. Main results. Seventy-six articles were included with a total of 48,439 ETS-exposed women and 90,918 unexposed women. ETS-exposed infants weighed less [WMD –60 g, 95% confidence interval (CI) –80 to –39 g], with a trend towards increased low birthweight (LBW, < 2,500 g; RR 1.16; 95% CI 0.99–1.36), although the duration of gestation and preterm delivery were similar (WMD 0.02 weeks, 95% CI –0.09 to 0.12 weeks and RR 1.07; 95% CI 0.93–1.22). ETS-exposed infants had longer infant lengths (1.75 cm; 95% CI 1.37–2.12 cm), increased risks of congenital anomalies (OR 1.17; 95% CI 1.03–1.34) and a trend towards smaller head circumferences (–0.11 cm; 95% CI –0.22 to 0.01 cm). Conclusions. ETS-exposed women have increased risks of infants with lower birthweight, congenital anomalies, longer lengths, and trends towards smaller head circumferences and LBW.