Objective: To investigate the risk of congenital anomalies in relation to an index of geographic density of landfill sites across 565 km grid squares in England. Methods: 2 km zones were constructed in a geographical information system around 8804 landfill sites, including 607 that handled special (hazardous) wastes, and intersected with postcode coordinates of over 10 million births (136 821 with congenital anomalies), 1983-98. A landfill exposure index was calculated to represent the geographic density of landfill sites within 2 km of births for each 565 km grid square, calculated separately for landfill sites handling special, and nonspecial or unknown, waste. For each group of landfills, the index was classified into four categories of intensity, and risks for the second, third and top categories were compared to the bottom category, comprising areas with no such landfill sites within 2 km (index of zero). We used hierarchical logistic regression modelling in a Bayesian framework, with adjustment for potential confounding.