Strengthening Recruitment and Retention: Mitigation Strategies in Two Longitudinal Studies of Pregnant Women in Pakistan

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. 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. Challenges we encountered include economic hardship and access to healthcare; women’s 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. 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. Recruitment and retention of pregnant women is challenging in any research context, for a range of socioecological reasons, including societal, community-level and individual factors. These issues can be more emphasized or play out in unique ways in studies conducted in low-middle-income countries. This study describes recruitment and retention challenges we encountered during our research in Pakistan. For each of these challenges, which may result in non-compliance if not addressed, the development and implementation of culturally safe and successful mitigation strategies is described. The knowledge gleaned may support future global health research teams setting out to conduct research in Pakistan, and perhaps other low-middle-income countries.