High pregnancy incidence and low contraceptive use among a prospective cohort of female entertainment and sex workers in Phnom Penh, Cambodia

Factors influencing maternal death in Cambodia, Laos, Myanmar, and Vietnam countries: A systematic review

BACKGROUND

A maternal mortality ratio is a sensitive indicator when comparing the overall maternal health between countries and its very high figure indicates the failure of maternal healthcare efforts. Cambodia, Laos, Myanmar, and Vietnam-CLMV countries are the low-income countries of the South-East Asia region where their maternal mortality ratios are disproportionately high. This systematic review aimed to summarize all possible factors influencing maternal mortality in CLMV countries.

METHODS

This systematic review applied "The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Checklist (2020)", Three key phrases: "Maternal Mortality and Health Outcome", "Maternal Healthcare Interventions" and "CLMV Countries" were used for the literature search. 75 full-text papers were systematically selected from three databases (PubMed, Google Scholar and Hinari). Two stages of data analysis were descriptive analysis of the general information of the included papers and qualitative analysis of key findings.

RESULTS

Poor family income, illiteracy, low education levels, living in poor households, and agricultural and unskilled manual job types of mothers contributed to insufficient antenatal care. Maternal factors like non-marital status and sex-associated work were highly associated with induced abortions while being rural women, ethnic minorities, poor maternal knowledge and attitudes, certain social and cultural beliefs and husbands' influences directly contributed to the limitations of maternal healthcare services. Maternal factors that made more contributions to poor maternal healthcare outcomes included lower quintiles of wealth index, maternal smoking and drinking behaviours, early and elderly age at marriage, over 35 years pregnancies, unfavourable birth history, gender-based violence experiences, multigravida and higher parity. Higher unmet needs and lower demands for maternal healthcare services occurred among women living far from healthcare facilities. Regarding the maternal healthcare workforce, the quality and number of healthcare providers, the development of healthcare infrastructures and human resource management policy appeared to be arguable. Concerning maternal healthcare service use, the provisions of mobile and outreach maternal healthcare services were inconvenient and limited.

CONCLUSION

Low utilization rates were due to several supply-side constraints. The results will advance knowledge about maternal healthcare and mortality and provide a valuable summary to policymakers for developing policies and strategies promoting high-quality maternal healthcare.

Global epidemiology of abortion among female sex workers: a systematic review, meta-analysis, and meta-regression

PURPOSE

Despite the evidence of a high rate of unintended pregnancy, there remains limited information about the prevalence and experiences of abortion among female sex workers (FSWs). In response, we aimed to summarize the available evidence on abortion among FSWs.

METHODS

We searched Medline, Embase, PsycINFO, CINAHL, Scopus, and Web of Science from inception to January 29, 2023 . We pooled data from the included studies using random-effects meta-analyses. We also grouped countries for the legality of elective abortion stratified by the United Nations database on abortion laws and policies.

RESULTS

We identified 60 eligible studies from 2031 potentially eligible records. The pooled lifetime prevalence of at least one and multiple induced abortions was 37.7% (95% confidence interval, 31.8-43.7) and 21.7% (14.9-29.2), respectively. Among FSWs recruited in countries where elective abortion is illegal, at least one induced abortion prevalence was 35.1% (28.1-42.4), and multiple induced abortion prevalence was 23.1% (12.4-35.9). In countries where elective abortion is legal, at least one induced abortion prevalence was 44.6% (34.8-54.6), and multiple induced abortion prevalence was 19.9% (11.9-29.3). Among FSWs experiencing abortion, self-managed abortion prevalence was estimated at 32.8% (23.6-42.7) overall, 42.8% (37.2-48.5) for countries where elective abortion is illegal, and 15.6% (3.9-32.7) for countries that legally allow elective abortion.

CONCLUSIONS

Induced abortion is prevalent among FSWs, highlighting the need for interventions to increase access to effective contraception and safe abortion care. While induced abortion prevalence did not significantly differ across the legal grounds for abortion, self-managed abortion prevalence was higher in countries where elective abortion was illegal, highlighting the urgent need for accessible abortion services for FSWs in criminalized settings. Moving forward necessitates implementing and evaluating culturally acceptable models of safe abortion and post-abortion care for FSWs to increase access to the full spectrum of sexual and reproductive health services.

Longitudinal study of pregnancy intention and its association with pregnancy occurrence among female sex workers in Benin and Mali

BACKGROUND

The intention of becoming pregnant has an evident impact on the prenatal and postnatal period. For female sex workers (FSWs) in West Africa, among whom pregnancies are frequent as are HIV and sexually transmitted infections, a better understanding of their pregnancy intention and its influence on pregnancy occurrence could help prevent unwanted pregnancies and adverse effects on wanted pregnancies.

METHODS

We recruited 330 FSWs in Benin and 322 in Mali and followed them for 12 months. We evaluated their pregnancy intention at recruitment and 6-month follow-up, using a multidimensional prospective measure that we developed. We assessed pregnancy occurrence with a pregnancy test and a retrospective questionnaire at 6 and 12 months. A Cox proportional hazard model was used to estimate the association between intention and pregnancy. We carried out an analysis to take losses to follow-up into account using the inverse of probability of censoring weights and a cluster analysis to corroborate that the multidimensional measure of pregnancy intention fitted the data.

RESULTS

407 FSWs were included in the first 6-month analysis and 284 at 12 months. Mean age was 30.9 years. The pregnancy intention distribution was similar between the two periods: 15.2% in the first period and 16.3% in the second had a positive intention. One out of four were ambivalent and almost 60% (57.7% and 56.3%) had a negative intention. For 38.2% of the FSWs, the intention changed between the two periods. The global incidence rate (to first event) was 19.1 pregnancies per 100 person-years. There was a borderline significant trend (p = 0.0529) of decreased pregnancy incidence with decreasing intention. Compared to positive intention, the adjusted hazard ratio (aHR) for ambivalent and negative intentions were 0.71 [95% confidence interval (95% CI) 0.32-1.60] and 0.46 (95% CI 0.21-1.01), respectively.

CONCLUSION

The level of pregnancy intention influences its occurrence among FSWs and nearly one out of six wants a baby despite working in the sex trade. Programmatically, early identification of these women could facilitate provision of quality antenatal and postnatal care. Given other health risks associated with sex work this care may decrease potential risks of adverse maternal, fetal and neonatal outcomes.

Values and preferences of contraceptive methods: a mixed-methods study among sex workers from diverse settings

There is limited information on contraceptive values and preferences of sex workers. We conducted a mixed-method study to explore contraceptive values and preferences among sex workers. We conducted an online survey with individuals from 38 countries (n = 239), 6 focus group discussions (FGD, n = 68) in Zimbabwe, and 12 in-depth phone interviews (IDI) across 4 world regions, in June and July of 2019. Participants were asked about awareness of contraceptives, methods they had used in the past, and the determinants of their choices. Differences between respondents from high-, low- and middle- income countries were examined. Qualitative data were analysed thematically. Survey participants reported an awareness of modern contraceptive methods. FGDs found that younger women had lower awareness. Reports of condomless sex were common and modern contraceptive use was inconsistent. Determinants of contraceptive choices differed by setting according to results of the survey, FGD, and IDI. Regardless of country income level, determinants of contraceptive choices included ease of use, ease of access to a contraceptive method, and fewer side effects. Healthcare provider attitudes, availability of methods, and clinic schedules were important considerations. Most sex workers are aware of contraceptives, but barriers include male partners/clients, side effects, and health system factors such as access and clinic attitudes towards sex workers.

Multilevel analysis of the role of women's empowerment on use of contraceptive methods among married Cambodian women: evidence from demographic health surveys between 2005 and 2014

Background

The use of contraceptives is an essential public health concept that improves overall safe motherhood and infant health. Women empowerment has been reported to influence health behaviors in women. With recent efforts to increase access to contraceptive methods, uptake of the same remains a challenge in Cambodia. There are limited studies that have examined the role of women’s empowerment at both individual- and community- level on contraceptive use in Cambodia. This study examined the individual- and community-level factors associated with contraceptive use among Cambodian married women between 2005 and 2014.

Methods

Data from 2005, 2010, and 2014 Cambodia Demographic and Health Surveys were used to analyze 2211; 10,505; and 10,849 women, respectively. Multilevel binary and multinomial logistic regression models were applied to assess the association between individual- and community- level factors, and the use of contraceptive methods.

Results

The prevalence of using modern contraceptive methods increased over time (i.e., 29.0, 38.1, and 42.3% in 2005, 2010, and 2014, respectively). At the individual level, women who attained secondary and higher education were more likely to use any contraceptives [adjusted odds ratio (aOR) = 1.43, 95% confidence interval (CI) = 1.22–1.68, and aOR = 1.23, 95% CI = 1.05–1.44 in 2010 and 2014, respectively] compared with those with no formal education. Similarly, having a high workforce participation level was significantly associated with increased likelihood of using any contraceptive methods [aOR = 1.12, 95% CI = 1.00–1.26, aOR = 1.44, 95% CI = 1.29–1.60 and in 2010 and 2014, respectively]. Other factors such as age at first marriage, residence, and having a health insurance were associated with contraceptive use. The proportional change in variance showed that about 14.3% of total variations in the odds of contraceptive use across the communities were explained by both individual- and community-level factors. Moreover, the intraclass correlation showed that about 5.2% of the total variation remained unexplained even after adjustments.

Conclusion

Both individual- and community- level factors influenced contraceptive use in Cambodia. When designing programs to improve contraceptive use, contextual influences should be taken into account for the effectiveness of the programs.

Overview and factors associated with pregnancies and abortions occurring in sex workers in Benin

Background

Behavioural and structural factors related to sex work, place female sex workers (FSWs) at high risk of maternal mortality and morbidity (MMM), with a large portion due to unintended pregnancies and abortions. In the African context where MMM is the highest in the world, understanding the frequency and determinants of pregnancy and abortion among FSWs is important in order to meet their sexual and reproductive health needs.

Methods

Data from two Beninese cross-sectional surveys among FSWs aged 18+ (2013, N = 450; 2016, N = 504) were merged. We first performed exploratory univariate analyses to identify factors associated with pregnancy and abortion (p < 0.20) using Generalized Estimating Equations with Poisson regression and robust variance. Multivariate analyses first included all variables identified in the univariate models and backward selection (p ≤ 0.05) was used to generate the final models.

Results

Median age was 39 years (N = 866). The proportion of FSWs reporting at least one pregnancy during sex work practice was 16.4%, of whom 42.3% had more than one. Most pregnancies ended with an abortion (67.6%). In multivariate analyses, younger age, longer duration in sex work, previous HIV testing, having a boyfriend and not using condoms with him were significantly (p < 0.05) associated with more pregnancies.

Conclusion

One FSW out of five had at least one pregnancy during her sex work practice. Most of those pregnancies, regardless of their origin, ended with an abortion. Improving access to various forms of contraception and safe abortion is the key to reducing unintended pregnancies and consequently, MMM among FSWs in Benin.

Systematic Review of Contraceptive Use Among Sex Workers in North America

OBJECTIVE

To systematically review the literature regarding contraceptive use by sex workers in North America and to understand factors that limit reproductive agency and affect contraceptive use and decision making.

DATA SOURCES

We searched PubMed, CINAHL, and Embase databases using the search terms "sex work(ers)," "transactional sex," "exchange sex," "prostitution," "contraception," "contraceptive agents," "birth control," "female," and "women."

STUDY SELECTION

Articles were eligible for inclusion in this review if they (a) reported quantitative or qualitative studies based in North America, (b) were written in English, (c) included sex workers (self-identified sex workers or engaged in sex work behavior) as the primary or secondary population of the study, (d) included a population assigned female sex at birth, (e) reported contraceptive outcomes for sex workers, and (f) were published in peer-reviewed journals. The initial search yielded 2,455 articles, and seven met the inclusion criteria.

DATA EXTRACTION

Two authors independently reviewed the articles and organized data in a table to capture study design, sample size and study population, study aims, and contraceptive use. We applied Connell's theory of gender and power as an analytic framework to further identify factors that limited reproductive agency.

DATA SYNTHESIS

Condoms were the most common method of contraceptive used across studies. The use of contraceptives varied by partner type (client vs. nonpaying intimate partners). Access to highly effective contraception was limited by perceived stigma, financial constraints, and substance use. Reproductive and harm reduction services that were co-located where women worked improved contraceptive use. Contraceptive use was affected by factors that limited reproductive agency, including stigma, substance use, intimate partner violence, and condom coercion.

CONCLUSION

The reliance of sex workers on partner-dependent contraception, such as condoms, combined with factors that limit reproductive agency over contraceptive use and decision making contribute to high potential for contraceptive failure and unintended pregnancy. More research is needed to understand the influence of different sexual partner types, pregnancy intention, and contraceptive decision making on the reproductive agency of sex workers.

Childhood conditions, pathways to entertainment work and current practices of female entertainment workers in Cambodia: Baseline findings from the Mobile Link trial

Background

Entertainment venues have been identified as an important location for HIV prevention due to the increasing number of young female entertainment and sex workers at these venues. The purpose of this study is to increase understanding of the childhood conditions, pathways to entertainment work and current practices of female entertainment workers (FEWs) in Cambodia.

Methods

Data used for this study were collected in April 2018 as part of the baseline survey of the Mobile Link, a randomized controlled trial to improve sexual and reproductive health of FEWs in Cambodia. We used a stratified random sampling method to recruit 600 FEWs for face-to-face interviews using a structured questionnaire. Descriptive analyses were performed.

Results

Most participants came from childhood homes without electricity (82.0%) or running water (87.0%). Most women moved to the city in the last ten years (80.5%) for economic reasons (43.7%). About a third worked in the garment industry prior to the entertainment industry (36.7%). Participation in transactional sex in the past three months was reported by 36.0%. Women reported low condom use practices with non-paying partners (23.4% used a condom at last sex), excessive and forced alcohol use at work (33.1% reported being forced to drink alcohol at work more than once a month), low modern contraception use (31.4% was using modern contraception), and experiences of gender-based violence (23.3% reported verbal threats, physical abuse or forced sex in the past six months).

Conclusions

This information will help to support the development of future individual and structural level interventions for the safety and support of FEWs. In addition, these results may contribute to an evidence base that can inform policy level changes intended to support the realization of full human rights for entertainment works in Cambodia including the rights to health, safety and respectful employment.

Socio-historical evolution of the episiotomy practice: A literature review

Episiotomy is an enlargement of the vaginal orifice made by a surgical incision of the perineum. This review aimed to provide a socio-historical retrospective on the practice or episiotomy. Using the criteria from the PRISMA guidelines, the authors conducted a literature review, browsing twenty databases and several papers available in the gray literature. Sixty-four articles, seven reports, and fifteen books were selected. Through this study, four eras with different approaches to episiotomy practice could be identified: 1792-1920, 1920-1980, 1980-1996, and 1996-2018. This review shows that institutionalization and medicalization of birth lead to a systematic practice of episiotomy in many westernized countries until 1996. Lay questioning and evidence-based medicine may have reversed this trend into a restrictive practice. After making an inventory of the factors associated with the evolution of change in the rate of episiotomies, the review finally revealed that evolution of the practice of episiotomy has also been influenced by ideological, political, and social factors.

Brachial artery stiffening in healthy primigravidas is associated with weight gain and increased cardiac output

OBJECTIVE

To assess brachial artery distensibility and associated factors in healthy primigravidas.

METHODS

We assessed brachial artery distensibility using the DynaPulse 5,000A in 37 women each trimester, and 6-8 weeks and 1-5 years postpartum. Associations with physical and cardiometabolic measures were considered.

RESULTS

Mean (SE) brachial artery distensibility (%Δ/mmHg) decreased (stiffened) from 7.50 (0.20) 12-14 weeks to 6.93 (0.22) 36-38 weeks (p < .01) and returned to baseline 7.52 (0.44) at 2.7 years postpartum. Weight gain and greater cardiac output were significantly related to greater stiffness.

CONCLUSION

Increased weight and cardiac output of pregnancy were associated with brachial artery stiffening.

Incidence of unintended pregnancy among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis

OBJECTIVES

To determine the incidence of unintended pregnancy among female sex workers (FSWs) in low-income and middle-income countries (LMICs).

DESIGN

We searched MEDLINE, PsychInfo, Embase and Popline for papers published in English between January 2000 and January 2016, and Web of Science and Proquest for conference abstracts. Meta-analysis was performed on the primary outcomes using random effects models, with subgroup analysis used to explore heterogeneity.

PARTICIPANTS

Eligible studies targeted FSWs aged 15-49 years living or working in an LMIC.

OUTCOME MEASURES

Studies were eligible if they provided data on one of two primary outcomes: incidence of unintended pregnancy and incidence of pregnancy where intention is undefined. Secondary outcomes were also extracted when they were reported in included studies: incidence of induced abortion; incidence of birth; and correlates/predictors of pregnancy or unintended pregnancy.

RESULTS

Twenty-five eligible studies were identified from 3866 articles. Methodological quality was low overall. Unintended pregnancy incidence showed high heterogeneity (I²>95%), ranging from 7.2 to 59.6 per 100 person-years across 10 studies. Study design and duration were found to account for heterogeneity. On subgroup analysis, the three cohort studies in which no intervention was introduced had a pooled incidence of 27.1 per 100 person-years (95% CI 24.4 to 29.8; I²=0%). Incidence of pregnancy (intention undefined) was also highly heterogeneous, ranging from 2.0 to 23.4 per 100 person-years (15 studies).

CONCLUSIONS

Of the many studies examining FSWs' sexual and reproductive health in LMICs, very few measured pregnancy and fewer assessed pregnancy intention. Incidence varied widely, likely due to differences in study design, duration and baseline population risk, but was high in most studies, representing a considerable concern for this key population. Evidence-based approaches that place greater importance on unintended pregnancy prevention need to be incorporated into existing sexual and reproductive health programmes for FSWs.

PROSPERO REGISTRATION NUMBER

CRD42016029185.