BACKGROUND: Exposure to pollution from biomass fuel has been associated with low birthweight in some studies. Few studies have included exposure-response analyses. METHOD: We conducted a case-control study of biomass fuel use and reproductive outcome at high altitude in Peru. Cases (n=101) were full term births who were SGA (birth weight <10th percentile for gestational age). Controls (n=101) had a birthweight >/=10th percentile, and were matched to cases on birth week and residence. Biomass fuel use during pregnancy was determined by questionnaire. Carbon monoxide (CO) in the kitchen was measured in a subgroup (n=72). Logistic regression was used to estimate the effects of biofuel and CO on the risk of SGA, controlling for maternal education and parity. RESULTS: Among cases, 30%, 27% and 44% used gas, gas+biomass, and biomass, respectively, while the figures for controls were 39%, 33%, and 29%. The adjusted odds ratio (OR) for biomass fuel alone compared with gas alone was 4.5 (95% CI: 1.3, 15.5, p=0.02), while the OR for biomass+gas vs. gas alone was 2.1 (0.80-5.5) (p=0.13). Among the subgroup with measured CO, the mean 48-h kitchen CO levels were 4.8, 2.2 and 0.4ppm for biofuel only, biofuel+gas, and gas respectively. ORs by increasing tertile of CO level were 1.0, 1.16, and 3.53 (test for trend, p=0.02). The exposure-response trend corresponds well with one other study with analogous data. CONCLUSION: Despite limited sample size, our data suggest that maternal exposure to biomass smoke and CO, at high altitude, is associated with SGA among term births.