“I did not plan to have a baby. This is the outcome of our work”: a qualitative study exploring unintended pregnancy among female sex workers

Abstract

Background High number of unintended pregnancies—often leading to induced abortions—are reported among female sex workers (FSWs), highlighting a major unmet need for contraception. To better understand barriers to contraceptive use, we explored FSW’s pregnancy perceptions and experiences of unintended pregnancy. We hypothesized that sex work exacerbates barriers to contraceptive use and that FSW’s pregnancy perceptions and experiences of unintended pregnancy influence future commitment to contraceptive use. Methods We conducted in-depth interviews with 11 FSWs (January–June 2019) in Dar es Salaam, Tanzania. We purposively sampled FSWs with a positive pregnancy test from those participating in a HIV vaccine preparedness cohort. We used open ended questions to explore how FSWs make decisions when facing barriers to contraceptive use, dealing with unintended pregnancy and adhering to contraceptive use after experiencing unintended pregnancy. All interviews were conducted in Kiswahili, audio-recorded, transcribed and translated into English. Grounded theory approach was used to analyse transcripts. Open and selective coding was performed using Nvivo software. Results FSWs reported that sex work impedes good contraceptive behaviour because sex workers felt unable to negotiate consistent condom use, avoided health services due to stigma, missed monthly contraceptive supplies because of inconvenient clinic operating hours or skipped contraceptive pills when intoxicated after taking alcohol. FSWs who perceived pregnancy to be a burden terminated the pregnancy because of fear of loss of income during pregnancy or child rearing expenses in case child support was not assured by their partners. FSWs who perceived pregnancy to be a blessing decided to keep the pregnancy because they desired motherhood and hoped that children would bring prosperity. Family planning counselling and availability of contraceptives during postpartum care influenced the initiation of contraception among FSWs. Financial hardships related to childrearing or painful abortion experiences influenced FSWs’ commitment to good contraceptive practices. Conclusion Our results demonstrate that FSWs face barriers to initiating and adhering to contraceptive use because of sex work stigma, inability to negotiate condoms and failure to access medical services at their convenience. Our findings underscore the need to integrate contraceptive services with HIV programs serving FSWs in their areas of work.

Women Who Sell Sex in Eastern and Southern Africa: A Scoping Review of Non-Barrier Contraception, Pregnancy and Abortion

“…Variables include: personal factors – fear of side effects [ 10 , 51 ]. desire for (more) children [ 11 ], being nulliparous [ 46 ], history of incarceration or arrest [ 55 ], intoxication [ 42 ], and being older than 35 [ 31 ]; interpersonal factors—male partners’ or clients’ disapproval [ 10 ], physical or sexual abuse [9, 16], having a steady partner [ 51 ]; and systemic issues—poor clinic access [ 10 , 42 ], negative healthcare provider attitudes [ 10 ], and condom availability at work [ 55 ]. Use of non-barrier contraception was found in to be associated with ease of access, positive healthcare provider attitudes, conducive clinic schedules, fewer side effects [ 56 ], previous pregnancy, positive attitude to and knowledge of family planning, younger age, and lower education [ 18 ].…”

“…Participants in Lafort et al’s [ 38 ] study in Mozambique reported that the most lacking service was for the termination of unwanted pregnancies. Sex workers in Tanzania reported terminating their pregnancies because of fear of loss of income during pregnancy or because of child rearing expenses [ 42 ].…”

“…A number of barriers to contraceptive services were identified in the studies. These include: long clinic wait times [ 22 ]; having to pay medical fees [ 22 , 28 ]; being asked for bribes [ 38 ]; inconvenient clinic operating hours [ 22 , 42 ]; perceived compulsory HIV testing at clinics [ 22 ]; discriminatory provider-client interactions [ 22 ]; inadequate care [ 38 , 58 ]; paucity of available services [ 58 ]; stigmatisation [ 29 , 38 , 42 ]; breaches in confidentiality [ 38 ]; lack of transport [ 28 ]; negative partner influences [ 22 , 28 ].…”

Unmet Need for Contraception Among Female Sex Workers Initiating Oral Pre-Exposure Prophylaxis for HIV Prevention During Kenya's National Scale-Up: Results From a Programmatic Surveillance Study

“…Additionally, barriers to contraceptive use for FSWs that warrant the attention of PrEP programs have also been uncovered through qualitative studies. These barriers include unsupportive clinic infrastructure, such as long wait times, inconvenient operating hours, and perceived compulsory HIV testing; discriminatory provider-client interactions; negative partner influences; laws that criminalize sex work, among others ( 7 , 18 , 25 , 26 ).…”

Factors associated with the uptake of long-acting reversible contraception among female sex workers in post-conflict Northern Uganda: a cross-sectional study

“…In Uganda, multiple studies reported very high rates of unintended pregnancies among FSWs [5,[8][9][10]-an indirect indicator of the high unmet need for contraception in this underserved population. Instead of LARC, FSWs of reproductive age tend to use the less reliable short-acting reversible contraceptives, especially condom [11]. Yet, condom use does not provide complete protection against pregnancy among the FSWs due to the rampant inconsistency of condom use along with condom breakage in this population [12][13][14][15][16][17][18].…”