Last week, the Women and Health Initiative at the Harvard T.H. Chan School of Public Health welcomed Saki Onda to speak about a vulnerable, understudied population: female sex workers (FSWs) and their children. Much of the global health research and programming efforts thus far have focused primarily on the prevention and treatment of sexually transmitted infections (STIs), and HIV in particular, among this population. The HIV infection risk is approximately thirteen times higher among FSWs compared to the general population. A number of factors put sex workers at greater risk of contracting STIs, including a lack of access to comprehensive sexual and reproductive health education and increased exposure to violence.
The issue of maternal mortality and morbidity among FSWs has been widely neglected in the public health literature. Along with colleagues Brian Willis and Hanni Marie Stoklosa, Saki recently published an article in BMC Public Health titled, “Causes of maternal and child mortality among Cambodian sex workers and their children: A cross sectional study.” The researchers interviewed 271 FSWs in Cambodia to explore the causes of maternal and child deaths. This was the first study examining these outcomes among sex workers.
The authors found distinct differences between the causes of maternal mortality among FSWs compared to non-FSWs: While postpartum hemorrhage and pre-eclampsia were the most common causes of maternal deaths in the general population, complications from abortion were the leading cause of maternal death among FSWs. The most common causes of death for children under 5 were HIV and infection among FSWs compared to prematurity and acute lower respiratory tract infections in the general population. While the results cannot be generalized because of the study design’s limitations, these preliminary findings warrant further investigation in different global settings using more robust methodology.
The FSWs who participated in the study reported experiences of disrespect and abuse from healthcare workers. One woman in Paraguay explained, “The majority of sex workers do not want to go for antenatal care because doctors do not treat them well because they are sex workers.” A woman in Uganda told the researchers that a nurse once told her, “You prostitutes go aside and we will treat the respectable people.” Especially in settings where sex work is illegal, FSWs may fear seeking care and disclosing their occupation to providers.
Given the vulnerability of FSWs and their children, increased global efforts to understand and address their sexual, reproductive and maternal health needs are critical. According to Saki, these efforts should involve a rights-based, evidence-informed approach, community engagement, comprehensive health services and a focus on ending stigma and discrimination.
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