Table 1.

Key research gaps in the study of nutritional status and malaria in pregnancy

	Research area
Burden	Evaluate the extent to which undernutrition and malaria in pregnancy co-exist • DHSS data, pooled analysis of relevant pregnancy cohort studies
Risk of malaria	Determine the relationship between maternal nutritional status and risk of malaria parasitaemia • Longitudinal cohort studies with frequent molecular infection monitoring
Effect modification	Determine whether malaria and nutritional status interact to worsen pregnancy outcomes (LBW, SGA, PTB, stillbirth) • Pooled analysis of pregnancy cohort studies, new longitudinal studies measuring most known confounders
Conception and early pregnancy	Examine effects of undernutrition and malaria at conception and in early pregnancy on outcomes • Longitudinal observational or interventional studies beginning before conception or in first trimester including repeated measures of malaria and nutritional status • Effect of early pregnancy malaria and undernutrition on rates of miscarriage, stillbirth, LBW
Concomitant micronutrient deficiencies	Investigate possible interactions between deficiencies of micronutrients such as iron and gestational malaria • Pregnancy cohort studies that evaluate malaria indices, micronutrient status, and pregnancy outcomes
Infant effects	Study the effects of maternal undernutrition and malaria on infant morbidity, mortality, growth and infection risk
	Evaluate the consequences of maternal undernutrition and malaria for development of the infant’s immune system Investigate whether children born with LBW due to undernutrition and/or malaria would benefit from increased nutritional support and malaria prevention in infancy • Longitudinal cohort studies with well-supported follow-up mechanisms • Randomised trials of packaged malaria and nutrition interventions for at-risk infants
Anthropometrics, cytokines and hormones	Relate anthropometric measurements in pregnancy to biochemical markers of nutritional status (albumin), regulators of the nutrition/immunity interface (e.g. leptin), and adverse pregnancy outcomes in malaria-endemic areas • Determine the interplay between undernutrition, Th1/Th2 balance, placental malaria-associated inflammation, and LBW
Gut function Antimalarial efficacy	Examine effects of environmental enteric dysfunction, and of changes in gut microbiome, on maternal nutrition and malaria susceptibility Evaluate the impact of macronutrient status on efficacy of antimalarials (including IPTp) in pregnant women.
Gestational weight gain	Evaluate strategies to improve gestational weight gain in undernourished women to counteract the effect of placental malaria • Combining nutrient or energy supplementation with antimalarial interventions Investigate novel mechanisms by which IPTp may work to improve maternal weight gain • Microbiome studies, pre and post IPTp, and using different IPTp candidates • Intestinal helminth – nutrition - malaria interactions
Antenatal care	Design and test approaches that integrate malaria-nutrition interventions • Combined or factorial trials of nutritional supplementation and malaria detection and prevention • Identify target groups for enhanced nutritional support and malaria protection, e.g. undernourished women, primigravidae, and adolescents.
Immunity	Examine the relationship between nutritional status and antibody-mediated immunity to PM, controlling for differences in malaria exposure among participants
	Evaluate the effect of nutritional intervention on antibody-mediated immunity to PM
Placental studies	Investigate potential overlapping effects of malaria and macronutrient undernutrition on placental nutrient transport

DHSS demographic and health surveillance system, PM placental malaria, LBW low birthweight, IPTp intermittent preventive treatment in pregnancy