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The aims of this study were: (1) to investigate the relationship between pre-delivery hemoglobin (Hb) concentration and the outcome of the pregnancy for the mother and child and (2) to assess the extent to which the pallor of the conjunctiva indicates severe anemia in pregnancy (Hb < 7 g/dl). We carried out a prospective study in 1995, in the maternity department of the National Sourô Sanou Hospital (Bobo-Dioulasso, Burkina Faso). Women arriving to give birth at the maternity unit gave verbal consent and underwent a physical examination including the assessment of conjunctiva coloration. Finger-prick blood samples were taken from all the women selected and Hb was determined with a portable hemoglobin meter (HemoCue AB, Sweden). For each woman, information about age, obstetric history, the condition of mother and child at admission and delivery and any post-delivery complications in the first 48 hours was collected before discharge from the maternity unit, 3 to 5 days after the delivery. Women with multiple pregnancies were excluded from the study and 247 women were included overall. Endometriosis was observed in only three cases. Three women died, two due to septic shock. The third woman died from hypovolemic shock. The Hb concentrations of these women were 8 g/dl, 10.2 g/dl and 2.6 g/dl respectively. The mean Hb concentration for our population was 10.1 g/dl (SD = 2.08), with 165 women (67%) having less than 11 g Hb/dl. Forty-one women (17%) had less than 9 g Hb/dl and 16 (6%) had less than 7 g Hb/dl. Severe maternal anemia and pallor of the conjunctiva were significantly associated with pre-term delivery and perinatal death, but not with low birth weight. The sensitivity of the pallor of the conjunctiva for detection of severe maternal anemia was 87%, and its specificity was 88%. We found no evidence that maternal Hb levels of 9 to 10.9 g/dl were associated with a high risk of poor pregnancy outcome for either the mother or the child, although women with such levels of Hb are classed as anemic by the World Health Organization criteria. These results show that poor pregnancy outcome is associated with severe maternal anemia. Examination of the coloration of the conjunctiva is a suitable and affordable screening method for the detection of severe anemia. Mothers with severe anemia present with signs and symptoms of anemia and could therefore be given iron treatment to improve their health. This demonstrates the importance of nutritional intervention during pregnancy.