Design Malarial anaemia is a major problem in many developing countries and often occurs more frequently in ?rst pregnancies, as primigravidae are more susceptible to Plasmodium falciparum malaria and are at excess risk of malarial anaemia. Objective and methods To analyse the excess risk of anaemia in primigravidae as a potential indicator of malaria control and exposure in pregnant women living in sub-Saharan Africa. The sensitivity, speci?city and predictive values for anaemia in ?rst compared with later pregnancies are calculated for 27 studies from malarious and 7 studies from nonmalarious areas. Setting Surveys of pregnancy anaemia reported for highly malarious and nonmalarious areas. Results In malarious areas, the weighted odds ratio for excess anaemia (haemoglobin [Hb] <11 g/dl) in primigravidae compared with multigravidae for all studies was 1.34 (95% CI 1.14–1.58). At an Hb cutoff below 8 g/dl, the weighted odds ratio was 1.79 (95% CI 1.52–2.10). In nonmalarious areas, there was no increased risk of anaemia in primigravidae with Hb below 11 g/dl (OR 0.80; 95% CI 0.63–1.90) or below 8 g/dl (OR 0.82, 95% CI 0.51–1.28). Conclusions In view of the consistency of results across highly malarious areas compared with nonmalarious areas, maternal anaemia has the potential to be used for surveillance of malaria control in pregnancy. Based on the analysis, an anaemia nomogram is developed for use as a surveillance indicator in malarious areas in sub-Saharan Africa