Plasmodium falciparum infection in pregnant women results in the chondroitin 4-sulfate-mediated adherence of the parasite-infected red blood cells (IRBCs) in the placenta, adversely affecting the health of the fetus and mother. We have previously shown that unusually low sulfated chondroitin sulfate proteoglycans (CSPGs) in the intervillous spaces of the placenta are the receptors for IRBC adhesion, which involves a chondroitin 4-sulfate motif consisting of six disaccharide moieties with ϳ30% 4-sulfated residues. However, it was puzzling how the placental CSPGs, which have only ϳ8% of the disaccharide 4-sulfated, could efficiently bind IRBCs. Thus, we undertook to determine the precise structural features of the CS chains of placental CSPGs that interact with IRBCs. We show that the placental CSPGs are a mixture of two major populations, which are similar by all criteria except differing in their sulfate contents; 2-3% and 9 -14% of the disaccharide units of the CS chains are 4-sulfated, and the remainder are nonsulfated. The majority of the sulfate groups in the CSPGs are clustered in CS chain domains consisting of 6 -14 repeating disaccharide units. While the sulfate-rich regions of the CS chains contain 20 -28% 4-sulfated disaccharides, the other regions have little or no sulfate. Further, we find that the placental CSPGs are able to efficiently bind IRBCs due to the presence of 4-sulfated disaccharide clusters. The oligosaccharides corresponding to the sulfate-rich domains of the CS chains efficiently inhibited IRBC adhesion. Thus, our data demonstrate, for the first time, the unique distribution of sulfate groups in the CS chains of placental CSPGs and that these sulfate-clustered domains have the necessary structural elements for the efficient adhesion of IRBCs, although the CS chains have an overall low degree of sulfation.A distinctive feature of Plasmodium falciparum compared with the other three human malaria parasites is its ability to express adherent protein(s) on the surfaces of the infected red blood cells (IRBCs) 1 and thereby sequester in the microvascular capillaries of various organs by adhering to endothelial cell surfaces (1-5). The extensive accumulation of IRBCs in vital organs causes capillary blockage with deprivation of oxygen and nutrients and production of toxic levels of proinflammatory cytokines (3, 6 -10), damaging the endothelial lining and causing organ dysfunction and severe pathological conditions. A number of studies have shown that the adherent protein expressed on the surfaces of IRBCs to be P. falciparum erythrocyte membrane protein 1 (EMP1), a multidomain, antigenic var gene family protein (11-17). P. falciparum EMP1 can bind, in a domain-specific manner, CD36, intercellular adhesion molecule-1, vascular cell adhesion molecule-1, E-selectin, platelet endothelial cell adhesion molecule-1/CD31, and thrombospondin on vascular endothelial cell surface (18 -24). In addition, P. falciparum EMP1 can also bind complement receptor (25), heparan sulfate (20), and chondroitin 4-sulfa...