Elsevier

Contraception

Volume 76, Issue 2, August 2007, Pages 105-110
Contraception

Original research article
Pregnancy among sex workers participating in a condom intervention trial highlights the need for dual protection

https://doi.org/10.1016/j.contraception.2007.04.009Get rights and content

Abstract

Background

Little is known about pregnancy rates among sex workers (SWs) or the factors that predispose SWs to this risk. We aimed to estimate the pregnancy incidence rate among Madagascar SWs participating in an intervention trial promoting use of male and female condoms and assess the influence of various predictive factors on pregnancy risk.

Methods

SWs from two study clinics in Madagascar participated in a randomized trial to assess the effect of peer education and clinic-based counseling on use of male and female condoms and prevalence of sexually transmitted infections (STIs). Women were seen every 2 months for up to 18 months; they received structured interviews at every visit, and physical exams at baseline and every 6 months thereafter. Site staff recorded information on pregnancies during interviews; pregnancy data were then merged with trial data for this analysis.

Results

Of 935 SWs in the analysis population, 250 became pregnant during follow-up. The cumulative probability of pregnancy was 0.149 at 6 months and 0.227 at 12 months. Comparable proportions of nonpregnant and pregnant SWs reported using highly effective contraception at baseline (∼16%); these users were younger and were more consistent condom users. Method switching and discontinuation were frequent. In multivariate analysis, nonuse of effective contraceptives and any self-reported unprotected sex were associated with higher incidence of pregnancy. Approximately 51% of women delivered, 13% reported a spontaneous abortion, 13% reported an induced abortion and 23% had missing pregnancy outcomes.

Conclusions

Women traditionally targeted for STI/HIV preventive interventions need more comprehensive reproductive health services. In particular, SWs could benefit from targeted family planning counseling and services.

Introduction

Public health interventions commonly target female sex workers (SWs) for disease prevention, largely ignoring their broader reproductive health needs. Most public health research involving SWs focuses on risk factors for HIV and other sexually transmitted infections (STIs). Inadequate attention has been dedicated to preventive behaviors and health outcomes associated with the other direct risk of sexual activity: pregnancy [1]. Addressing SWs' dual needs for contraception as well as STI/HIV prevention is essential given their high risk of pregnancy stemming from frequent sex with multiple partners. Comprehensive prevention services could help reduce the risk of adverse outcomes associated with unintended pregnancy, ranging from the dangers of unsafe abortion to poor birth outcomes caused by compromised maternal health status. Furthermore, in SW populations with high HIV prevalence, provision of contraceptives to SWs not desiring pregnancy is a means of preventing vertical HIV transmission by reducing the risk of unplanned pregnancy in HIV-infected women [2].

The few studies that have reported on pregnancy among SWs have shown high incidence of undesired pregnancy. In a survey conducted with 475 SWs in Kenya, for example, 86% of the respondents admitted to having at least one lifetime abortion, and 50% reported more than one [3]. Qualitative research conducted with Cambodian SWs found that current use of contraceptives (besides condoms) was rare and abortion was widely practiced [4].

Here we report on secondary data collected during a trial conducted with Madagascar SWs to measure the effect of male and female condoms on STI outcomes. We also recorded data on contraceptive use and pregnancy occurrence and outcomes during 18 months of follow-up. This paper presents the results of analyses of pregnancy incidence and the influence of various predictive factors on pregnancy risk and presents the pregnancy outcomes among these women.

Section snippets

Outline of randomized controlled trial

Female SWs in two cities in Madagascar (Antananarivo and Tamatave) were enrolled in a randomized controlled trial (RCT) to measure the effect of peer education only vs. peer education plus clinic-based counseling on protected sex and STIs [5], [6]. Participants were seen every 2 months for up to 18 months, at which time they received structured interviews. They underwent physical exams at baseline and every 6 months thereafter. At each study visit and through ad hoc contact in the community,

Features of the population

Among the 935 women included in the analysis, three-fifths were under 30 years of age (Table 1). Most women at baseline reported unprotected intercourse with clients. About 40% of women stated they had a nonpaying partner; among those with a nonpaying partner, most women reported unprotected intercourse with them.

Contraceptive use in the cohort

Use of highly effective contraceptives was rare, mainly injectables or pills, and remained steady at 15–17% through Month 18. Such use was associated with younger age and higher condom

Discussion

More than one quarter of women in our study cohort conceived a recognized pregnancy within 18 months, most of which were detected within 12 months. The 12-month pregnancy rate was about 23 per 100 women. As is typical in contraceptive trials, the pregnancy risk was highest early in the study. The life table pregnancy probability was 0.091 in Months 0–4; 0.095 in Months 4–8; and 0.041 in Months 8–12. And like a contraceptive trial, pregnancy was associated with nonuse of an effective method.

The

Acknowledgments

Support for this work was provided by Family Health International (FHI) with funds from the U.S. Agency for International Development (USAID). The views expressed in this article, however, do not necessarily reflect those of USAID. FHI is an international nonprofit organization that conducts research and provides technical assistance in health, family planning, STIs and AIDS. The authors thank the two study teams and the Laboratoire National de Référence VIH/SIDA for their untiring efforts in

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