Enrolling pregnant women in research: ethical challenges encountered in Lao PDR (Laos)

Laos has the highest maternal mortality ratio in mainland Southeast Asia but there has been little research conducted with pregnant women. We aim to discuss ethical challenges in enrolling pregnant women in research as a part of large pregnancy cohort study in Laos. From 2013 to 2015, a prospective cohort study was conducted with 1000 pregnant women in a rural area of Vientiane, Laos, to determine whether fevers were associated with maternal morbidity and small for gestational age. Incidence of fever was 10% and incidence of small for gestational age was 12%. Level of education, cultural norms about family decision-making, and misconceptions about healthcare during pregnancy were three common issues encountered in enrolling pregnant women to this study. Only 47% of recruited women had completed primary school with no further education, which could affect the decisions women make to participate and remain in the study. Family decision-making is common in Laos; in some cases, we could not recruit pregnant women without agreement from their families. In Laos, many pregnant women and their families had strong beliefs in travelling during late pregnancy or losing small amount of blood (giving ~5 ml blood sample) could negatively impact their pregnancies. These misconceptions affected not only the quality of the study but also the women's opportunities to access healthcare. Good engagement between the research team and study participants, and the provision of more health information to the community, were essential to reducing issues experienced in enrolling pregnant women in this study.