| Summary: | <h4>Background</h4> We determined whether dimensions of psychosocial distress during pregnancy individually and collectively predicted preterm birth (PTB) in Pakistani women as it may be misleading to extrapolate results from literature predominantly conducted in high-income countries. <h4>Methods</h4> This cohort study included 1603 women recruited from four Aga Khan Hospital for Women and Children in Sindh, Pakistan. The primary binary outcome of PTB (i.e., livebirth before 37 completed weeks’ gestation) was regressed on self-reported symptoms of anxiety (Pregnancy-Related Anxiety (PRA) Scale and Spielberger State-Trait Anxiety Inventory Form Y-1), depression (Edinburgh Perinatal Depression Scale (EPDS)), and covariates such as chronic stress (Perceived Stress Scale) assessed with standardized question and scales with established language equivalency (Sindhi and Urdu). <h4>Results</h4> All 1603 births occurred between 24 and 43 completed weeks’ gestation. PRA was a stronger predictor of PTB than other types of antenatal psychosocial distress conditions. Chronic stress had no effect on the strength of association between PRA and PTB and a slight but non-significant effect on depression. A planned pregnancy significantly lowered risk of PTB among women who experienced PRA. Aggregate antenatal psychosocial distress did not improve model prediction over PRA. <h4>Conclusions</h4> Like studies in high-income countries, PRA became a strong predictor of PTB when considering interactive effects of whether the current pregnancy was planned. Women’s resilience and abilities to make sexual and reproductive health decisions are important to integrate in future research. Findings should be generalized with caution as socio-cultural context is a likely effect modifier. We did not consider protective/strength-oriented factors, such as resilience among women.
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