Robert Gilman
Peru
Bloomberg School of Public Health, MS program
BACKGROUND: Anemia and iron deficiency during gestation remain a concern of Peruvian healthcare providers as the prevalence of anemia during pregnancy is uncertain, estimated as anywhere between 38-50 percent in Peru. The concern of negative birth outcomes that may be associated with deteriorating iron status of the mother, combined with the high prevalence of anemia, indicate that maternal iron status and its correlates require better understanding. The country of Peru, however, is extremely diverse, both geographically and culturally, and therefore indicators of maternal health should be interpreted cautiously in accordance with such variations. Observations made in one geographic area or cultural enclave may not be generalizable to the country as a whole. Recently, the use of hemoglobin to assess iron status has been questioned as to whether it is the best method available. To further confound the analysis of anemia among pregnant women is the fact that the criteria to determine anemia have been ascertained from data taken from populations residing at low altitudes and extrapolated to establish estimated hemoglobin cutoff values for women residing in high altitudes.
AIM: The purpose of this study was to further characterize the iron status of pregnant women in Peru by studying samples of women in their third trimester of pregnancy residing at a low altitude site in Lima, Peru (268m) and comparing them to women residing at a high altitude site in Huaraz, Peru (3091m).  PARTICIPANTS AND METHODS: Blood samples were collected from more than 150 pregnant women in each site to determine the iron status via analysis of hemoglobin, serum transferrin, and transferrin receptor measurements. A baseline interview was conducted with each participant to collect information pertaining to social and economic factors, past pregnancies, antenatal care, and other nutritional and health related behaviors. We reviewed post-partum medical records so as to assess pregnancy outcomes by acquiring information pertaining to gestational age, APGAR scores, birth weight and length, and birth complications. Fecal samples were collected from participants in Huaraz to identify anemia due to intestinal parasitic infection.
 RESULTS: Preliminary results demonstrated mean hemoglobin levels of 117 + 15.8g/L and 126 + 11.8g/L in Lima and Huaraz where cutoff levels to determine anemia are 110g/L and 129g/L, respectively. Prevalence of anemia was thus determined to be 33.58% (CI: 25.7, 42.1) and 56.69% (CI: 48.6, 64.5) in these populations. Final results are pending laboratory analysis and data collection of newborn health outcomes.
Characterization of maternal anemia among varying populations is necessary to make informed healthcare decisions as to the most appropriate anemia prevention and treatment programs. Additionally, comparison of test results will further complement the body of knowledge regarding the most efficient methods to determine iron status and anemia and thus assist in standardization of analytical criteria. It is hoped that results from this study will help to improve the precision with which healthcare providers determine the prevalence of anemia at high altitudes in Peru.
With the aid of the Framework Program in Global Health grant, I have been able to travel to Peru as an investigator in maternal health. I designed the study to analyze the varying qualitative and quantitative factors associated with the iron status of pregnant women, with the assistance and support of a fellow student and JHSPH faculty. I traveled to Peru, where I stayed from August 2006 to June 2007. There, I conducted all aspects of the research including contacting and corresponding with local healthcare providers and ethics committees, management of research staff, and data collection (blood samples, questionnaires, health record information etc), data management, and analysis. Furthermore, I developed a close network of fellow students, investigators, and other contacts with whom I will be able to correspond in the future. Living in both Huaraz and Lima, Peru, I became accustomed to and appreciated the diversity in culture, and combined with my research, I have been able develop a better understanding of the ways in which daily life affect the healthcare of the women in these settings. The well-rounded quality of this experience has taught me much more than I could have hoped any standard internship would provide, has exemplified the details that I had learned during my coursework at JHSPH, and has given me many skills that I will carry with me into future research endeavors.
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