This study employed an observational, cross-sectional, and correlational design. Data were collected from 184 medical records of postpartum women treated at Sergio Bernales Hospital in 2022 (ethics under Ethics Certificate 1,208-2023-CIEI-UPSJB). Cognitive function was assessed after nearly three years (ethics under Ethics Certificate 0353-2025-CIEI-UPSJB) using a 3D video game based on selective attention (Torres-Tejada et al., 2020) and multitasking paradigms (Mugruza-Vassallo et al., 2021). Statistical analysis included chi-square tests, odds ratios (OR), and ANOVA.

The study population consisted of postpartum women diagnosed with anemia and treated at the Department of Gynecology and Obstetrics at Sergio Bernales Hospital in Peru between February and December 2022. A sample of 184 women was selected using probabilistic random sampling. For cognitive testing, 15 women with anemia and 15 without anemia were assessed in 2025. The Hospital Nacional Sergio Bernales, located in Lima, Peru, serves a population of approximately 2.3 million people, making it a critical center for studying postpartum anemia in the region.

Clinical and gynecological data were collected via standardized forms extracting information from medical records. Variables included sociodemographic factors (age, residence, occupation, education, income), clinical factors (cesarean delivery, uterine atony, prenatal care, parity, body mass index), and obstetric factors (interpregnancy interval, gestational age).

Cognitive function was assessed using a Unity 3D-based 3D video game (Torres-Tejada et al., 2020) using visual warning cues (Posner et al., 1980), which measured reaction times to visual stimuli and multitasking performance (see Figure 1). Two distinct 3D games evaluated cognitive function in participants with and without anemia. Game Design:

Descriptive statistics were used to summarize the data. Chi-square tests and odds ratios were used to assess associations between risk factors and postpartum anemia. To compare the reaction times between participants in the “WITH” (“CON”) and “WITHOUT” (“SIN”) anemia groups, a one-way analysis of variance (ANOVA) was conducted. The ANOVA was performed using the f_oneway function from the scipy.stats module in Python. This statistical test was chosen to determine if there were significant differences in reaction times (Tiempo) between the two groups at both videogames, followed by one-way ANOVAs for post hoc group comparisons. Assumptions of homogeneity of variance were confirmed via Levene’s test (p = 0.646).

A two-way ANOVA (α = 0.05) assessed main effects (Game Type and Anemia Condition) and interaction.

Table 1 summarizes the sociodemographic characteristics of postpartum women treated at Sergio Bernales Hospital in 2022, highlighting the prevalence of postpartum anemia across different categories such as age, residence, employment status, education level, and household income.

The analysis identified several significant risk factors for postpartum anemia, as summarized in Table 1. Cesarean delivery was associated with a 3.32-fold increased risk (OR = 3.320, p = 0.048), while uterine atony showed a 6.12-fold increased risk (OR = 6.120, p = 0.032). Lack of prenatal care had the strongest association, with a 9.12-fold increased risk (OR = 9.117, p = 0.004). Obesity (OR = 7.120, p = 0.003), an intergenesic period of less than 3 years (OR = 9.720, p = 0.025), and preterm gestational age (OR = 4.530, p = 0.015) were also significant risk factors (Table 2).

These findings highlight the multifactorial nature of postpartum anemia and underscore the importance of addressing these risk factors to reduce its prevalence. Interventions such as improved prenatal care, nutritional support, and optimal birth spacing could play a crucial role in reducing the burden of postpartum anemia and its associated complications.

The findings highlight the multifactorial nature of postpartum anemia, with cesarean delivery, uterine atony, and lack of prenatal care being significant risk factors. These results align with previous studies, such as Casavilca (2017), who found a strong association between cesarean delivery and postpartum anemia. Recent research by Neef et al. (2024) underscores the importance of early detection and treatment of postpartum anemia, particularly through iron supplementation, which has been shown to significantly improve maternal well-being and outcomes. Our study adds to this body of evidence by demonstrating the long-term cognitive impacts of postpartum anemia, further emphasizing the need for timely intervention.

Significant differences in reaction times were observed between anemic and non-anemic women in both Game 1 (p = 0.014) and Game 2 (p < 0.001). The impact of anemia on cognitive function, particularly selective attention, was evident in the 3D video game experiments. These findings align with Jakobsen et al. (2011), who validated reaction time as a measure of cognitive health, and Lalitha et al. (2024), who demonstrated that pregnant women with anemia exhibit significantly longer RTs compared to non-anemic pregnant women. The consistency of these findings across different populations highlights the importance of addressing anemia to mitigate its cognitive effects.

Furthermore, Takahashi et al. (2024) showed that 3D video games can effectively assess executive functions in children with ADHD, suggesting that such tools have broad applicability for cognitive assessment across different populations and conditions.

The long-term RT deficits observed in anemic women align with growing evidence that anemia disrupts neural plasticity. Hypoxia reduces Brain-derived neurotrophic factor (BDNF) availability and synaptic strength in prefrontal cortex (Duderstadt et al., 2024), potentially impairing the brain’s ability to adapt to postpartum demands. While our study did not measure neurobiological markers, the 3D video game paradigm indirectly probes plasticity-dependent processes (e.g., attentional tuning). Future research combining hemoglobin assays with fMRI or transcranial stimulation could clarify how anemia alters postpartum neuroplasticity.

The slower RTs observed in anemic women may reflect broader disruptions in spatial cognition. Hippocampal place cells encode location relative to environmental geometry (O'Keefe and Burgess, 1996), and human navigation relies on landmark-boundary integration (Hartley et al., 2004). While our task was not explicitly navigational, the 3D stimuli required participants to rapidly localize targets within a bounded virtual space—a process potentially dependent on hippocampal-entorhinal circuits. Anemia-induced hypoxia could impair this spatial-attentional integration, compounding RT delays. Future studies could explicitly test boundary-based attention (e.g., varying target proximity to virtual walls) to dissociate hippocampal contributions.

In addition to selective attention, multitasking abilities are crucial for daily functioning, particularly in the context of information and communication technologies (ICT). The increasing integration of ICT into daily life has heightened the demand for multitasking, which can be particularly challenging for individuals with cognitive impairments.

The integration of ICT in this study, particularly the use of 3D video games, provides a novel approach to assessing cognitive function in postpartum women. This aligns with the work of Mugruza-Vassallo et al. (2022), demonstrated that different Markov chains can modulate visual stimuli processing in various environments differently for women and men showcasing ICT’s potential in cognitive assessments. Furthermore, Takahashi et al. (2024) showed that 3D video games can effectively assess executive functions in children with ADHD, suggesting that such tools have broad applicability for cognitive assessment across different populations and conditions. García et al. (2017) also highlighted the use of augmented reality and 3D environments to provide immersive experiences that enhance cognitive evaluations, particularly beneficial for understanding impairments in older adults.

While the use of a 3D video game provided a novel and ecologically valid approach to assessing cognitive function, it is important to consider the limitations of this methodology in Torres-Tejada et al., 2020, our study extends this approach to postpartum women,

The cognitive consequences of technology dependence extend beyond our 3D video game paradigm. Recent work by Kosmyna et al. (2025) demonstrates that overreliance on AI tools (e.g., ChatGPT for writing) can erode neural engagement and self-monitoring capacity, as evidenced by reduced EEG connectivity and poorer recall in LLM-dependent users. While our study highlights anemia’s biological disruption of attention (e.g., slower RTs), Kosmyna’s findings reveal a behavioral analogue: both chronic anemia and habitual AI use may engender ‘cognitive debt’—where short-term efficiency gains compromise long-term executive function. This parallel underscores the need to contextualize cognitive health within modern technological demands. For postpartum women, whose multitasking burdens are heightened by caregiving, interventions must balance ICT-assisted assessments (like our 3D game) with strategies to sustain endogenous attention resilience.

The significant differences in reaction times between anemic and non-anemic women (Game 1: p = 0.014; Game 2: p < 0.001) suggest that postpartum anemia may impair executive function, particularly in tasks requiring selective attention and cognitive flexibility. Executive function encompasses higher-order cognitive processes such as attention, working memory, and the ability to switch between tasks, all of which are critical for effective multitasking and decision-making (Takahashi et al., 2024). The slower reaction times observed in anemic women may reflect deficits in these domains, consistent with prior research linking anemia to impaired cognitive performance (Beard et al., 2005; Agrawal et al., 2019).

Furthermore, the multitasking component of the 3D video game required participants to process multiple stimuli simultaneously, a task that heavily relies on executive function. The poorer performance of anemic women in this task suggests that postpartum anemia may specifically affect the ability to manage competing cognitive demands, a key aspect of executive function. These findings align with studies demonstrating the utility of video games in assessing executive dysfunction in other populations, such as children with ADHD (Takahashi et al., 2024).

The prolonged RTs in anemic women may reflect deficits in attentional disengagement, akin to invalid cue trials in Posner tasks. Future studies could adapt our 3D paradigm to include Posner-like cueing (Posner and Rothbart, 2007), isolating specific attentional subsystems (e.g., orienting, alerting in Fan et al., 2002) affected by postpartum anemia. Also, more conditions in the event-related methods (Mugruza-Vassallo and Potter, 2019) or frequency domain method (wavelet feature) or entropy features in non-linear dynamic method (Guo et al., 2022) may allow to study cognitive load (Mugruza-Vassallo, 2023) in anemia.

The integration of ICT in healthcare not only addresses individual health issues but also contributes to societal well-being by improving maternal health outcomes and reducing the burden of cognitive impairments on families and communities (Araujo et al., 2024; Nikam and Motwani, 2024). This is particularly relevant given the findings of Neef et al. (2024), who highlight the significant impact of postpartum anemia on maternal physical and mental health, and Greig et al. (2013), who demonstrated that iron deficiency in women of childbearing age negatively impacts cognition, mental health, and fatigue. Additionally, Susič et al. (2023) used machine learning to predict depression and fatigue in postpartum anemia patients, demonstrating the potential of advanced technologies to improve the detection and management of these conditions. Garrido Bustamante et al. (2024) further emphasized the effectiveness of ICT in managing immediate postpartum anemia, highlighting personalized monitoring and early interventions as key strategies. While the benefits of ICT in healthcare are substantial, challenges such as the digital divide and access disparities remain critical issues that need addressing to ensure equitable health outcomes for all women, particularly in developing regions (Nihlani and Rana, 2024).

Despite the significance of our findings, several limitations should be acknowledged. First, although the study initially included 184 women to check typical postpartum population, the final sample consisted of 30 women, which was relatively small, particularly for the cognitive testing component conducted over a 3-year period. Although we made efforts to recruit additional participants, the longitudinal nature of the study posed challenges in retaining a larger cohort. It is important to emphasize that our study targeted a particularly difficult-to-recruit population: postpartum women with anemia and our study is event-related, meaning that small methodological variations can be applied across EEG, fMRI, or eye-tracking studies. This specificity makes our final sample size more notable. Compared to other longitudinal studies with shorter follow-up periods, our retention rate is reasonable. For example, in an not event-related task, Casey (2000) conducted a non-event-related 6-month longitudinal study with three groups—10 women planning pregnancy, 18 first trimester pregnant women, and 24 non-pregnant controls—who completed the study. Similarly, Barda et al. (2021) conducted a 2-years study in 40 pregnant and 40 non-pregnant women. Larger sample sizes are needed in future research to strengthen the generalizability of our findings and reduce heterogeneity.

Second, the study did not standardize the type of medication taken by participants in both groups. Variations in medication use may have influenced cognitive performance and reaction times, introducing potential confounding factors. Future studies should standardize medications or control for their effects when including subjects to ensure more robust and reliable results.

Finally, the 3-year follow-up period, while providing valuable longitudinal data, may have introduced variability due to changes in participants’ health, lifestyle, or environmental factors over time. Also other sensing modalities may be affected by plasticity, as prior studies in blind people (Föcker et al., 2012). Future studies should consider shorter follow-up intervals or more frequent assessments to minimize these effects and capture more precise data on cognitive changes.