PURPOSE: Global health researchers have a responsibility to conduct ethical research in a manner that is culturally respectful and safe. The purpose of this work is to describe our experiences with recruitment and retention in Pakistan, a low-middle-income country. DESCRIPTION: We draw on two studies with a combined sample of 2161 low-risk pregnant women who participated in a pilot (n = 300) and a larger (n = 1861) prospective study of psychological distress and preterm birth at one of four centers (Garden, Hyderabad, Kharadar, Karimabad) of the Aga Khan University Hospital in Karachi, Pakistan. ASSESSMENT: Challenges we encountered include economic hardship and access to healthcare; womens position in the family; safety concerns and time commitment; misconceptions and mistrust in the research process; and concerns related to blood draws. To mitigate these challenges, we developed culturally acceptable study incentives, involved family members in the decision-making process about study participation, partnered with participants obstetrician-gynecologists, accommodated off site study visits, combined research visits with regular prenatal care visits, and modified research participation related to blood draws for some women. CONCLUSION: Implementation of these mitigation strategies improved recruitment and retention success, and we are confident that the solutions presented will support future scientists in addressing sociocultural challenges while embarking on collaborative research projects in Pakistan and other low-middle-income countries.

Anxiety and depression commonly co-occur during pregnancy and may increase risk of poor birth outcomes including preterm birth and low birth weight. Our understanding of rates, patterns, and predictors of comorbid anxiety and depression is hindered given the dearth of literature, particularly in low- and middle-income (LMI) countries. The aim of this study is (1) to explore the prevalence and patterns of comorbid antenatal anxiety and depressive symptoms in the mild-to-severe and moderate-to-severe categories among women in a LMI country like Pakistan and (2) to understand the risk factors for comorbid anxiety and depressive symptoms. Using a prospective cohort design, a diverse sample of 300 pregnant women from four centers of Aga Khan Hospital for Women and Children in Pakistan were enrolled in the study. Comorbid anxiety and depression during pregnancy were high and numerous factors predicted increased likelihood of comorbidity, including: (1) High level of perceived stress at any time point, (2) having 3 or more previous children, and (3) having one or more adverse childhood experiences. These risks were increased if the husband was employed in the private sector. Early identification and treatment of mental health comorbidities may contribute to decreased adverse birth outcomes in LMI countries.