Maternal anaemia may shape infant brain development

Jessica Ellen Ringshaw, a neuropsychologist who recently completed her PhD in Paediatric Neuroscience as a Wellcome Trust Fellow at the University of Cape Town’s (UCT) Neuroscience Institute, has led the first study using ultra-low-field Magnetic Resonance Imaging (MRI) to demonstrate the association between antenatal maternal anaemia and altered infant brain structure.

These novel findings have been published in Brain Communications, a high-impact open-access journal, and made available to South Africans via an online educational video resource. Combining world-leading research with public engagement, this project demonstrates how scientific findings can advance knowledge and have meaningful impact beyond academia.

As the recipient of a Wellcome Trust International Training Fellowship, Ringshaw was funded to complete her PhD, with the unique opportunity for specialised training in neuroimaging at the Centre for Neuroimaging Sciences, King’s College London (KCL). Under the supervision of Professor Kirsty Donald (deputy director of the Neuroscience Institute, UCT), Professor Steve Williams (head of Neuroimaging, KCL), and the late Professor Dan Stein (former head of Psychiatry, UCT), Ringshaw’s neuroimaging research investigated the effects of antenatal maternal anaemia on child brain structure and development in early life.

This included answering important questions of clinical relevance using traditional high-field (3 T) MRI, as well as cross-validation work assessing a novel ultra-low-field (64 mT) MRI system’s comparative feasibility in under-resourced settings.

Addressing anaemia as a global health priority

Anaemia, characterised by low serum haemoglobin, is a well-recognised global health priority affecting more than one third of women worldwide. However, the burden of disease is unevenly distributed with a much higher prevalence observed in low- and middle-income countries, particularly in sub-Saharan Africa and South Asia. Despite being included in World Health Organization (WHO) 2030 nutrition targets as a Sustainable Development Goal for accelerated action, progress in reducing anaemia has stagnated over the last two decades.

“Anaemia must be placed at the forefront of public health efforts if we are to see children not just surviving but thriving.”

“The most recent 2025 WHO report indicates that the global prevalence of anaemia among women of reproductive age has not improved and, in fact, seems to be rising. Based on projections from current trends (2012–2023), we are unlikely to achieve the WHO target of a 50% reduction in anaemia prevalence at global, regional, and national levels,” Ringshaw said. “This means that, now more than ever, anaemia must be placed at the forefront of public health efforts if we are to see children not just surviving but thriving.”

Ringshaw has advanced understanding of antenatal maternal anaemia (during pregnancy) and neurodevelopment through research published exclusively in open-access journals, ensuring widespread dissemination of her academic findings.

This includes epidemiological research on the prevalence and profile of iron deficiency anaemia in South African mothers and infants with inflammation (PLOS Global Public Health), high-field neuroimaging research on the persistent effects of maternal anaemia in pregnancy on child brain structure in toddlers and school-age children (BMC Medicine), and cross-validation research assessing agreement between high-field and ultra-low-field volume estimates for brain regions previously linked to anaemia (Human Brain Mapping).

Novel neuroimaging research using ultra-low-field MRI

Today, Ringshaw’s final PhD manuscript, representing the culmination of all this work, has been published in Brain Communications and is titled “Antenatal Maternal Anaemia and Infant Brain Structure: High-field (3 T) and Ultra-Low-Field (64 mT) Findings from South Africa”.

This study is nested within Khula, an observational South African birth cohort study funded by Wellcome Leap and led by principal investigator, Professor Donald. More broadly, the work was conducted as members of Ultra-low-field Neuroimaging In The Young (UNITY), an international network funded by the Gates Foundation and led by Professor Williams, with the aim of increasing neuroimaging access to improve maternal and child health.

In this latest publication, Ringshaw and colleagues are the first to demonstrate that the impact of maternal anaemia in pregnancy on child brain structure is evident as early as infancy, with effects becoming detectable on brain volumes at 12 months of age in this cohort.

Antenatal maternal anaemia, even when mild, was associated with reduced total brain volumes in infants, as well as smaller volumes of specific brain regions, including the corpus callosum (-6%), caudate nucleus (-4%), and putamen (-3%). This neuroimaging work builds on previous South African research by Ringshaw and colleagues on toddlers and school-age children, demonstrating reliably comparable brain volume differences in the same brain regions (ranging between 4 and 8% reductions) across age groups and studies.

“Taken together, this research corroborates antenatal maternal anaemia as an important risk factor for altered child brain structure, with findings that remain regionally consistent and that persist with age from infancy throughout the first six to seven years of childhood.”

In discussing these findings, Ringshaw reports that antenatal maternal anaemia may be associated with an increased risk of lasting cognitive impairment that may become especially apparent at school age. These potential difficulties can be explained by the brain regions affected by maternal anaemia, with the corpus callosum and basal ganglia playing important roles in processing speed, executive functioning, emotion regulation, and spatial reasoning.

Ringshaw’s Brain Communications article concludes that the research findings have the ability to inform global recommendations for the timing and optimisation of anaemia management, reinforcing the importance of prevention and intervention in women of reproductive age both before and during pregnancy. Given the similarities in overall brain growth trajectories and observed volumetric differences by maternal anaemia status across MRI field strengths, this study also suggests that the ultra-low-field system may provide sufficient sensitivity for detecting the effects of anaemia on the infant brain. “Beyond its direct implications for policy and practice, this work marks an important step forward in validating ultra-low-field MRI for anaemia research in regions with limited neuroimaging access, where the burden of anaemia is greatest and where many children remain at risk of not reaching their full developmental potential,” Ringshaw explained.

The power of pairing scientific discovery with public engagement

In parallel to the primary research fellowship, Ringshaw was also awarded a Wellcome Trust Research Enrichment grant with supplementary funding for public engagement. This supported a three-tiered project including interactive community-based workshops with mothers from the study, the development of accessible and culturally-appropriate resources, and the dissemination of study findings on public platforms.

In December 2023, Ringshaw designed and ran workshops titled “Neuroimaging and Nutrition: Engaging with Mothers Around Child Brain Development” with the support of a team of colleagues including researchers, clinicians, translators, and a dietician. The aim of the workshops was to identify practical ways to improve research processes and to gain insight into community perceptions, as well as challenges around risk and protective factors for neurodevelopment. “It was inspiring to participate in group discussions that had such energy and enthusiasm both from Jessica and our team leading the workshop, and from the mothers and fathers who participated,” Professor Donald said. You could feel the commitment to understanding each other in efforts to offer children the best start in life.”

One of the mothers attending the workshop described it as a “great initiative”, emphasising that “there are very few resources in the townships and get[ing] to learn, go back and implement, and share and observe – it makes a little bit go far!”

Based on the workshop feedback, and drawing upon the published research findings, Ringshaw then scripted and directed an animated video titled “Nourishment and Neurodevelopment: The Importance of Nutrition for Your Child’s Brain Health”. This educational resource is aimed at mothers and caregivers with practical information on local, familiar, and accessible food products from South African grocery stores.

The content was informed by reciprocal dialogue between researchers with expertise in child development, mothers from Gugulethu, and a dietician familiar with the common practices, practical considerations, and challenges experienced by mothers in this context. The video was funded by Ringshaw’s Wellcome Trust research enrichment grant and is available in three South African languages (English, Afrikaans, and isiXhosa). It is an open-access resource with shareable YouTube links and the series has been published on the UCT Public Engagement for Neurodevelopment and Neuroimaging of the Young (PENNY) website.

“The opportunity to do meaningful scientific research paired with public engagement has been such a rewarding and heartwarming part of my career, and I am proud to be part of a collaborative effort founded on a joint investment in the future of our children. This educational video is a tribute to the South African communities that make this work so important, and the people who have inspired me to pursue a career in maternal health and child development. My aspiration is that it will foster the dissemination of key messages across South African communities with the recognition of mothers and caregivers as key stakeholders in research and as important voices for community-led knowledge sharing,” Ringshaw said.

Paving the way forward

Ringshaw and colleagues have proven that cutting-edge research and meaningful public engagement can and should work together to maximise scientific and societal impact. This approach demonstrates how health research can advance discovery while empowering communities, informing policy, and paving the way for more equitable research and healthcare in the future.

Reflecting on the achievement, Ringshaw noted that it is a testament to the collective effort behind the science, paying tribute to the colleagues, collaborators, and mentors whose support, expertise, and dedication have shaped both her career and the research itself.

Looking ahead, she hopes more researchers will be inspired to embrace both scientific pursuits and meaningful engagement with the communities their work aims to serve. “My sincere gratitude is owed to my brilliant supervisors who have been role models of both leadership and mentorship, my co-authors on this paper including the data collection team who made this work possible, and my dedicated colleagues at UCT and KCL who I have the privilege of working alongside. I am also incredibly grateful to the mothers, caregivers, and children who eagerly participated in our studies and public engagement initiatives for the benefit of our community and country. They have given this work purpose and meaning, touched my heart in innumerable ways, and reminded me of what truly matters in the world.”