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Abstract

Background:

High proportions of female sex workers (FSWs) become pregnant and have children. Many FSWs are at increased risk of maternal health complications due to factors such as poverty, violence, and healthcare barriers. Despite this, FSWs’ maternal health and use of maternal health services (MHS) receive limited attention.

Objectives:

The objectives of this scoping review are to (1) synthesize existing data on FSWs’ maternal health and MHS utilization and (2) assess the state of peer-reviewed literature on FSWs’ maternal health in regard to methodological approaches and reported outcomes.

Eligibility criteria:

Included articles were peer-reviewed, published in English, and reported empirical data on FSWs for outcomes related to antenatal care, pregnancy, and labor complications, postnatal and delivery care, and/or barriers to MHS.

Sources of evidence:

Article searches were conducted in PubMed, Web of Science, Global Health, Sociological Abstracts, Sociological Index, PsychInfo, and CINAHL

Charting methods:

Information extracted from eligible articles included publication year, study design, location, sample size, outcome measures, and findings. The “Three Delays” model was used to synthesize findings on barriers to MHS as relevant to phase I, II, or III delays.

Results:

Eighteen publications met the eligibility criteria. Studies were conducted in 11 countries and primarily reported quantitative data from cross-sectional surveys. The most frequently reported outcome was antenatal care utilization (n = 14), whereas few studies reported findings related to postnatal care and breastfeeding counseling (n = 2). Across publications, there was a substantial range in the proportion of FSWs who reported accessing different types of MHS.

Conclusion:

Literature on FSWs’ maternal health is limited and heterogenous. More research is needed that specifically focuses on measuring outcomes related to FSWs’ maternal health and examines associated factors. Such work can inform future research directions and public health interventions for FSWs—a population of marginalized women whose maternal health has been overlooked in existing efforts.

Keywords

antenatal care female sex workers maternal health pregnancy prenatal care scoping review sex work

Introduction

Public health research on female sex workers (FSWs) has primarily focused on the prevention of sexually transmitted infections (STIs), with limited consideration of the broader health needs of this population. In particular, the maternal health of FSWs has remained overlooked despite the high prevalence and incidence of pregnancy among various populations of FSWs worldwide.^1
–4 Further, in recent studies based in Canada, the Dominican Republic, and Kenya, over 20% of FSWs surveyed expressed fertility desires or reported actively trying to conceive.^5
–7 Given the high numbers of FSWs who become pregnant and give birth, a more comprehensive understanding of FSWs’ maternal health and engagement in maternal health care is needed.

Maternal health care encompasses the provision of services that promote positive health outcomes for women during pregnancy, childbirth, and the postnatal period.⁸ Prior work has demonstrated that women who receive antenatal, intrapartum, and postnatal care from skilled professionals experience fewer pregnancy complications, require less invasive medical interventions during birth, and demonstrate improved outcomes in the postnatal period compared to women who do not receive this care.^9
–12 Given such findings, the World Health Organization released a series of updated, evidence-based guidelines for the optimal delivery of maternal health services (MHS). These guidelines recommend that pregnant women have a minimum of eight antenatal care (ANC) contacts, initiate ANC within 12 weeks of pregnancy, receive antenatal screenings for HIV and other locally relevant STIs, have skilled birth personnel attend deliveries, have a minimum of four postnatal care (PNC) contacts within 42 days of childbirth, and receive breastfeeding counseling.^13
–15 Improvements in the implementation of MHS guided by such recommendations have contributed to a 38% reduction in the global maternal mortality ratio from 2000 to 2017.¹⁶

Timely access to the full spectrum of maternal health care can be impeded by a variety of individual-level, interpersonal, and structural obstacles. One widely used conceptual model for mapping factors that facilitate delays in women’s access to appropriate MHS is the “Three Delays” model.¹⁷ This model posits that there are three critical phases in the process of pursuing MHS where delays can occur: (1) delays in the decision to seek care (phase I); (2) delays in physically accessing a health facility (phase II); and (3) delays in the provision of adequate care when at a healthcare facility (phase III). The occurrence and impact of these delays are influenced by various factors such as the affordability of care, illness recognition, distance to medical facilities, and the actual or perceived quality of care available.¹⁷ While the Three Delays model was originally proposed to understand the occurrence of preventable deaths from emergency obstetric complications, it has since been adapted to a wider range of health outcomes including the general utilization of MHS.^18
–21

Previous work has already highlighted the myriad of barriers that impede or delay sex workers’ utilization of general health services. For example, past experiences of discrimination from medical providers and a fear of further discrimination have been shown to deter FSWs from accessing HIV-related services, treatment for injuries, and mental health care.^22
–25 A growing body of evidence also indicates that punitive laws that criminalize sex work and activities associated with sex work (e.g., client solicitation) deter sex workers from accessing health services and disclosing pertinent information to medical providers.^26
–28 In the context of the Three Delays model, factors such as the fear of criminal punishment or anticipated stigma could contribute to delays in FSWs’ decisions to seek MHS (phase I delay), while factors such as discrimination by medical providers could facilitate delays in the provision of adequate care (phase III delay). Importantly, whether such delays are actually reflected in the existing literature on FSWs’ maternal health has not been extensively investigated.

Improving our understanding of FSWs’ utilization of MHS and the barriers they face to receiving such care is of critical importance since the full continuum of recommended MHS could uniquely benefit FSWs in several ways. For example, FSWs have more than 13 times the burden of HIV compared to the general population of women, and use of MHS during pregnancy could help identify undiagnosed HIV infections, engage women in antiretroviral treatment plans, and reduce the risk of mother-to-child transmission of HIV.^29,30 In addition, many FSWs are at higher risk of pregnancy and labor complications due to factors such as housing instability, violence, poverty, and untreated substance use disorders.^31
–34 Engagement in comprehensive MHS could help mitigate the impact of these factors on FSWs’ maternal health outcomes and facilitate linkage to supportive services.

Ultimately, in considering the high prevalence of pregnancy among FSWs, the magnitude of barriers that impede sex workers’ general health care access, and the unique benefits of MHS utilization for this population, a review of the existing literature on FSWs’ maternal health is warranted to better understand their engagement with MHS and the factors that influence this. Thus, the objectives of this scoping review are to (1) synthesize existing data on FSWs’ maternal health and use of MHS and (2) assess the state of peer-reviewed literature on FSWs’ maternal health in regards to methodological approaches and reported outcomes. Critically, determining the extent to which FSWs engage with MHS, experience pregnancy or labor complications, and encounter barriers to care can help inform future research and public health action aimed at improving health outcomes for a population of women that has been historically overlooked in the field of maternal health.

Methods

Scoping reviews produce a broad overview of the size and scope of the existing literature on a subject and are useful for identifying research gaps, summarizing the types of evidence available, and informing future research directions. This review was conducted in adherence with PRISMA Scoping Review guidelines.³⁵ A protocol for this review was not published.

Information sources and search strategy

A comprehensive search of seven health-related databases (PubMed, Web of Science, Global Health, Sociological Abstracts, Sociological Index, PsychInfo, and CINAHL) was conducted on February 20, 2022. The following search strategy was used: (“sex work*” OR “commercial sex” OR “sex industry” OR “sex trade” OR “FSW” OR “prostitut*” OR “sell sex” OR “selling sex”) AND (“pregnant” OR “pregnancy” OR “antenatal” OR “prenatal” OR “postnatal” OR “perinatal” OR “peripartum” OR “intrapartum” OR “postpartum” OR “obstetric care” OR “obstetrics” OR “maternal health” OR “maternal” OR “mother-child transmission” OR “PMTCT” OR “mother-to-child transmission” OR “skilled birth” OR “childbirth” OR “breastfeeding”). Search results were restricted to those that included these terms in the title and/or abstract. In addition, the search conducted in PubMed included the following Medical Subject Heading terms: “sex work,” “sex workers,” “pregnant women,” “prenatal care,” “perinatal care,” and “maternal health services.”

On January 17, 2023, the search was rerun in each database to identify additional studies that were published or added to databases after the initial search. The same search strategy was used but, when possible, search results were restricted to publications that were entered into a database after the date of the initial search. If this was not possible, then results were restricted to those published after the initial search date.

Inclusion criteria

Articles were considered for inclusion in this review if they were published in English in a peer-reviewed journal. Included articles could be qualitative or quantitative investigations so long as they presented empirical data on at least one of the following outcomes: any use of ANC, number of ANC contacts during a pregnancy, timing of ANC initiation, antenatal HIV/STI screening, HIV/STI diagnoses during pregnancy or delivery, any maternal health complications identified during pregnancy or delivery, presence of skilled birth personnel during delivery, any PNC, receipt of breastfeeding counseling, and/or specification of barriers experienced to MHS. Articles were excluded if they were not published in English, were not peer-reviewed, did not report data specific to FSWs with pregnancy experience, and did not report findings on one of the aforementioned outcomes. Commentaries, reviews, and protocols were also excluded.

Study selection

Search results were uploaded into Endnote and duplicate articles were removed using the protocol reported by Bramer et al.³⁶ The remaining search results were then uploaded to Covidence—a collaborative tool for conducting systematic reviews. Two reviewers used Covidence to independently screen the titles and abstracts of each article and exclude those that did not meet inclusion criteria. Following this, both reviewers read the complete texts of all remaining articles. During this full-text review, articles that did not meet the inclusion criteria were excluded and reasons for exclusion were documented. Any conflicts that arose in the review of titles/abstracts or full-text were discussed and resolved until consensus between the two reviewers was attained. Consistent with scoping review guidelines, we did not conduct a formal quality appraisal of study methodologies or the likelihood and degree of bias in the findings presented.³⁵

Data extraction

Both reviewers independently extracted the following data from each article that met inclusion criteria: first author(s), publication year, study location, period of data collection, study aims, study design, sampling method, inclusion criteria, sample size, type(s) of sex work participants engaged in, and data related to the outcomes of interest. For qualitative data, themes identified by authors were recorded along with quotes that provided evidence for these themes. Extraction was completed with a form designed in Covidence. Any conflicts in extraction results were discussed and resolved in order to achieve consensus between the two reviewers.

Synthesis

Characteristics of each included study were reported in tabular form. Similarly, results from included studies were reported in summary results tables and organized under the following four categories: (1) ANC utilization, (2) pregnancy and labor complications, (3) delivery and PNC utilization, and (4) barriers to MHS utilization. These categories were also used to organize a narrative synthesis of results. Due to heterogeneity in outcome measures and study characteristics, results were not pooled.

Results on barriers to MHS were predominately qualitative and were synthesized in the context of the Three Delays model.¹⁷ To summarize relevant results through this model, data were thematically analyzed and coded by the two reviewers as a factor relevant to a phase I, phase II, or phase III delay.

Results

Search results

Based on the search strategy employed, a total of 2641 records were initially identified. After removing duplicates, 1288 records remained. An additional 1215 records were excluded after title and abstract review. A full-text review was then conducted for the remaining 73 records. Among these 73 records, 22 met all criteria outlined above for study inclusion. During full-text reviews, seven publications were determined to have used the same datasets produced from three studies to report on similar outcomes.^37
–43 These records were merged to represent the three studies and results from one publication per study were extracted for this review. In total, 18 peer-reviewed publications were included in this review. A PRISMA flowchart describing the article selection process is depicted in Figure 1.

Figure 1.

PRISMA flow diagram of articles in review.

Characteristics of included publications

As shown in Table 1, studies were conducted in 11 different countries: the United States (n = 2),^38,44 the United Kingdom (n = 2),^45,46 India (n = 4),^47
–50 South Africa (n = 2),^51,52 Tanzania (n = 2),^53,54 Brazil (n = 1),⁴¹ Cameroon (n = 1),⁴⁰ Côte d’Ivoire (n = 1),⁵⁵ Bangladesh (n = 1),⁵⁶ Guinea-Bissau (n = 1),⁵⁷ and Papua New Guinea (n = 1).⁵⁸ The publication year of the included articles ranged from 1991 to 2022. The majority of included publications exclusively reported quantitative results from cross-sectional surveys (n = 13). However, three publications exclusively reported qualitative results from in-depth interviews^49,50,53 and two publications reported findings from mixed-methods studies.^44,51 While most studies (n = 11) did not recruit participants by type or location of sex work, four studies specifically recruited street-based sex workers,^38,44,45,49 and three studies recruited sex workers from venues such as bars or massage parlors.^46,53,54

Table 1.

Study characteristics.

First Author	Study location(Study period)	Study design	Study inclusion criteria(Setting of sex work)	Sample size(s)	Outcome(s) examined
Deisher et al.³⁸	Seattle, Washington, United States (November 1987 to 1989)	Cross-sectional	Cisgender women aged 13-18 years old; have pregnancy or recent delivery experience; be engaged in sex work (Street-based)	Total sample: n = 54	• Any ANC^a • Number of ANC contacts • HIV/STI diagnosis during pregnancy or delivery • Other pregnancy and labor complications • Skilled birth personnel during delivery
Jeal and Salisbury⁴⁵	Bristol, England, United Kingdom (June to July 2001)	Cross-sectional	Cisgender women aged ⩾ 16 years; be engaged in street-based sex work in central Bristol (Street-based)	Total sample: n = 71 • n = 47 with pregnancy experience beyond 24 weeks	• Any ANC • Timing of ANC initiation
Jeal and Salisbury⁴⁶	Bristol, England, United Kingdom (June to July 2004)	Cross-sectional	Cisgender women aged ⩾ 16 years; be engaged in sex work in massage parlors in central Bristol (Venue-based)	Total sample: n = 71 • n = 37 with pregnancy experience beyond 24 weeks	• Timing of ANC initiation • Number of ANC contacts
Jain and Sharma⁴⁷	Madhya Pradesh, India	Cross-sectional	Cisgender women of the Berias ethnic group; have a history of a full-term pregnancy that resulted in delivery; be based in Rahatgarh Block of the Sagar district (General)	Total sample: n = 71	• Any ANC • Skilled birth personnel during delivery • Other pregnancy and labor complications
Becker et al.⁴⁸	Northern Karnataka, India (January to June 2011)	Cross-sectional	Cisgender women who formally began sex work within 5 years of study participation; live within three districts of northern Karnataka between January and June 2011; receive money/gifts in exchange for sex in the past year; be registered with local HIV/STI prevention program (General)	Total sample: n = 1011 • n = 251 with a pregnancy history • n = 197 who had ⩾ 1 birth	• Antenatal HIV/STI screening • Skilled birth personnel during delivery
Schwartz et al.⁵⁵	Abidjan, Cote d’Ivoire (March to July 2014)	Cross-sectional	Cisgender women aged ⩾ 18; acquire > 50% of income from sex work in past 12 months; reside in Abidjan for the past 3 months (General)	Total sample: n = 466 • n = 331 who had ⩾ 1 live birth	• Any ANC • Antenatal HIV/STI screening
Beckham et al.⁵³	Iringa and Njombe, Tanzania (February to July 2012)	Cross-sectional; qualitative	Cisgender women aged ⩾ 18; work in entertainment venues (e.g., bars); exchange sex for money within the past month of study participation (Venue-based)	Total sample: n = 30	• MHS barriers
Wahed et al.⁵⁶	Dhaka, Bangladesh (2015)	Cross-sectional	Cisgender women who engage in sex work; work in Dhaka city during study period; engage with registered drop-in centers for sex workers (General)	Total sample: n = 731 • n = 61 who gave birth in year prior to survey	• Any ANC • Number of ANC contacts • HIV/STI diagnosis during pregnancy or delivery • Skilled birth personnel during delivery • Other pregnancy and labor complications • Any PNC
Parmley et al.⁵¹	Port Elizabeth, South Africa (October to April 2015)	Cross-sectional; mixed-methods	Cisgender women aged ⩾ 18; live in Nelson Mandela Bay Metropolitan Municipality; report sex work as main source of income in year before study (General)	Total survey sample: n = 410 • n = 343 with pregnancy history • n = 313 with any birth history • n = 7 currently pregnant Total interview sample: n = 30	• Any ANC • Timing of ANC initiation • HIV/STI diagnosis during pregnancy or delivery • MHS barriers
Rwema et al.⁵²	Port Elizabeth, South Africa (October to April 2015)	Cross-sectional	Cisgender women aged ⩾ 18; live in Nelson Mandela Bay Metropolitan Municipality; report sex work as main source of income in year before study (General)	Total sample: n = 410 • n = 343 with pregnancy history • n = 192 with child(ren) aged < 5 years	• Antenatal HIV/STI screening • Skilled birth personnel during delivery • MHS barriers
Reno et al.⁴⁹	Mumbai, India (December 2018)	Cross-sectional; qualitative	Cisgender women engaged in sex work; work in Kamathipura red-light area of Mumbai, India; gave birth to ⩾ 1 child (Street-based)	Total sample: n = 25	• Breastfeeding counseling
Bowring et al.⁴⁰	Cameroon (December 2015 to October 2016)	Cross-sectional	Those assigned female sex at birth and aged ⩾ 18 years; report sex work as main source of income in previous year; speak English or French; reside in recruitment city for ⩾ 3 months before study recruitment (General)	Total sample: n = 2255 • n = 2058 with pregnancy history	• Any ANC
Beckham et al.⁵⁴	Iringa, Tanzania (October 2015 to April 2016)	Randomized controlled trial; cross-sectional survey	Cisgender women aged ⩾ 18 years; report exchanging sex for money in the month before study participation (Venue-based)	Total sample: n = 339 • n = 321 with pregnancy history	• Any ANC • MHS barriers
Braga et al.⁴¹	Brazil (July to November 2016)	Cross-sectional	Cisgender women aged ⩾ 18 years; work as sex worker in 1 of 12 study cities in Brazil; have at least 1 instance of sexual intercourse in exchange for money in 4 months preceding study participation (General)	Total sample: n = 4328 • n not reported for sample with pregnancy history	• Any ANC • Number of ANC contacts • Timing of ANC initiation
Dewey et al.⁴⁴	United States	Cross-sectional; mixed methods	Cisgender women who became pregnant and gave birth while using substances and engaging in street-based sex work; participate in a transitional housing program for women who left street sex trade and are in substance use recovery (Street-based)	Total case file sample: n = 125 Total interview sample: n = 55	• MHS barriers
Weikum et al.⁵⁸	Papua New Guinea (June 2016 to December 2017)	Cross-sectional	Those assigned female sex at birth and aged ⩾ 12 years; sold or exchanged vaginal sex in the past 6 months; speak English or Tok Pisin (General)	Total sample: n = 2901 • n = 400 with live birth ⩽ 3 years ago	• Any ANC • Antenatal HIV/STI screening • HIV/STI diagnosis during pregnancy or delivery
Grosso et al.⁵⁷	Guinea-Bissau (September to November 2017)	Cross-sectional	Those assigned female sex at birth and aged ⩾ 18; be a resident of a study city; earn over half of their income in the past 12 months from sex work (General)	Total sample: n = 505 • n = 494 with pregnancy experience	• Any ANC
Shewale and Sahay⁵⁰	Maharashtra, India (January 2016 to June 2019)	Cross-sectional; qualitative	Cisgender women aged 18-49; self-identify as a sex worker; reside in selected rural/urban blocks of Maharashtra (General)	Total sample: n = 29 • n = 26 with pregnancy experience	• MHS barriers

ANC: antenatal care; HIV: human immunodeficiency virus; STI: sexually transmitted infection; MHS: maternal health service(s); PNC: postnatal care.

Publications are derived from the same dataset but report unique outcomes, so they were presented separately.

ANC utilization

Of the 18 included publications, 14 reported at least one outcome related to ANC utilization (Table 2). A total of 11 articles reported data on the proportion of study participants who received any ANC during a past or current pregnancy, making it the most common maternal health outcome investigated. This proportion ranged from 50.7% of FSWs in Madhya Pradesh, India⁴⁷ to over 90% in Dhaka, Bangladesh, several cities in Brazil, and Port Moresby, Papua New Guinea.^41,56,58 Five publications also reported data on the number of ANC contacts that FSWs had during a current or prior pregnancy. From these five publications, the proportion of FSWs who had four or more ANC contacts ranged from 0% in Madhya Pradesh, India⁴⁷ to 83.9% in Belo Horizonte, Brazil.⁴¹ In addition, four articles reported results on the timing of ANC initiation, with three of the four articles measuring this as the proportion of FSWs who initiated care within the first 12 weeks of pregnancy. This proportion ranged from 35.2% in Salvador, Brazil to 80.6% in Porto Alegre, Brazil.⁴¹

Table 2.

Antenatal care, pregnancy and labor complications, delivery, and postnatal care.

Outcome	Findings % (n)^a	Citation
Antenatal care utilization
Any antenatal care	74.1% (n = 40/54)	Deisher et al.³⁸
	87.2% (n = 41/47)	Jeal and Salisbury⁴⁵
	50.7% (n = 36/71)	Jain and Sharma⁴⁷
	85.0% (n = 273/321)	Beckham et al.⁵³
	85.4% (n = 281/330)	Schwartz et al.⁵⁵
	91.8% (n = 56/61)	Wahed et al.⁵⁶
	89.7% (n = 304/339)	Parmley et al.⁵¹
	83.2% (n = 1712/2057)	Bowring et al.⁴⁰
	85.8%^b (95% CI: 82.1-88.8%)^b Range: 61.1% (Salvador) to 99.0% (Curitiba)	Braga et al.⁴¹
	71.5% (n = 213/298)	Grosso et al.⁵⁷
	88.3% (n = 353/400)^b Range: 84.4% (Mt. Hagen) to 92.2% (Port Moresby)	Weikum et al.⁵⁸
Number of antenatal care contacts	⩾ 9 contacts (for full-term births): 37.2% (n = 16/43) > 6 contacts by 31 weeks (for pre-term births): 8.3% (n = 1/12)	Deisher et al.³⁸
	0 contacts: 49.3% (n = 35/71) 1 contact: 36.6% (n = 26/71) 2 contacts: 14.1% (n = 10/71)	Jain and Sharma⁴⁷
	“Completed all recommended antenatal contacts”: 76% (n = 28/37)	Jeal and Salisbury⁴⁶
	0 contacts: 8.2% (n = 5/61) 1 contact: 9.8% (n = 6/61) 2 contacts: 29.5% (n = 18/61) 3 contacts: 24.6% (n = 15/61) ⩾ 4 contacts: 27.7% (n = 17/61)	Wahed et al.⁵⁶
	⩾ 7 contacts: 59.3% (CI: 53.6-64.8)^b Range: 28.0% (Salvador) to 83.9% (Belo Horizonte)	Braga et al.⁴¹
Timing of antenatal care initiation	Before 12 weeks: 51.1% (n = 24/47)	Jeal and Salisbury⁴⁵
	Before 12 weeks: 75.7% (n = 28/37)	Jeal and Salisbury⁴⁶
	Median week of initiation: week 19; range: 12-26 (n = 7)	Parmley et al.⁵¹
	Before 12 weeks: 63.9% (95% CI: 59.1-68.5%)^b Range: 35.2% (Salvador) to 80.6% (Porto Alegre)	Braga et al.⁴¹
Accessed antenatal HIV/STI screening	HIV: 55.4% (n = 139/251)	Rwema et al.⁵²
	HIV: 58.9% (n = 195/331)	Schwartz et al.⁵⁵
	HIV: 94% (n = 181/192)	Becker et al.⁴⁸
	HIV: 98.9% (n = 272/275)^b Range: 97.4% (Port Moresby) to 100% (Lae & Mt. Hagen)^c Syphilis: 84.3% (n = 97/115)^b Range: 80.6% (Mt. Hagen) – 88.5% (Lae)^c	Weikum et al.⁵⁸
	HIV: 98.9% (n = 272/275)^b Range: 97.4% (Port Moresby) to 100% (Lae & Mt. Hagen)^c Syphilis: 84.3% (n = 97/115)^b Range: 80.6% (Mt. Hagen) to 88.5% (Lae)^c	Weikum et al.⁵⁸
Pregnancy and labor complications
HIV/STI diagnosis in pregnancy or delivery	44.4% (n = 24/54)	Deisher et al.³⁸
	13.1% (n = 8/61)	Wahed et al.⁵⁶
	24.6% (n = 77/312)	Parmley et al.⁵¹
	16% (n = 15/94)^b Range: 8.3% (Mt. Hagen) to 19.2% (Port Moresby)^d	Weikum et al.⁵⁸
Other complications in pregnancy and labor	Pregnancy-induced hypertension: 15% (8/54) Abruption: 2% (1/54) Amnionitis: 2% (1/54)	Deisher et al.³⁸
	Weakness: 19.72% (14/71) Excessive bleeding: 14.08% (10/71) Excessive pain: 2.82% (2/71) Edema 1.41% (1/71)	Jain and Sharma⁴⁷
	Severe weakness: 60.7% Excessive bleeding: 41.0% Blurry vision: 26.2% Headache: 24.6% Edema: 24.6% Severe anemia: 16.4% Lower abdominal pain: 14.8%	Wahed et al.⁵⁶
	Severe weakness: 60.7% Excessive bleeding: 41.0% Blurry vision: 26.2% Headache: 24.6% Edema: 24.6% Severe anemia: 16.4% Lower abdominal pain: 14.8%	Wahed et al.⁵⁶
Delivery and postnatal care
Skilled attendance at birth	92.6% (50/54)	Deisher et al.³⁸
	50.7% (36/71)	Jain and Sharma⁴⁷
	55.8% (110/197)	Becker et al.⁴⁸
	54.1% (33/61)	Wahed et al.⁵⁶
	100% (192/192)	Rwema et al.⁵²
Any postnatal care	0 contacts: > 50% 2 + contacts: 23%	Wahed et al.⁵⁶
Breastfeeding counseling	Some women received infant feeding advice from medical providers that discouraged breastfeeding; they were told to use formula	Reno et al.⁴⁹

HIV: human immunodeficiency virus; STI: sexually transmitted infection.

Numbers may not reflect the full eligible sample due to missing responses.

Average proportion across study sites.

Of women who reported being offered an HIV or syphilis test.

Of women who reported receiving a syphilis test.

Four publications reported the prevalence of antenatal HIV/STI screening among FSWs.^48,52,55,58 For HIV screening, 94% of surveyed FSWs in Northern Karnataka, India⁴⁸ received antenatal HIV testing while lower screening prevalence was reported in Port Elizabeth, South Africa (55.4%)⁵² and Abidjan, Côte d’Ivoire (58.9%).⁵⁵ In Papua New Guinea, 79.8% of surveyed FSWs reported being offered an HIV test at an ANC visit during their last pregnancy and, of those offered, 98.9% actually received testing.⁵⁸ In addition, in this same study, 34.3% of FSWs reported being offered a syphilis test at an ANC visit during their last pregnancy. Of these women, 84.3% actually received syphilis testing.

Pregnancy and labor complications

Six of the 18 included publications reported data on pregnancy and/or labor complications among FSWs (Table 2). Four of these articles reported the proportion of FSWs who were diagnosed with HIV/STIs during pregnancy or delivery.^38,51,56,58 One publication focused on pregnant FSWs aged ⩽ 18 years in Seattle, Washington, reported that 44.4% of study participants were diagnosed with at least one STI at the time of delivery, and 14.8% were diagnosed with multiple infections.³⁸ In addition, in Dhaka, Bangladesh, 13.1% of FSWs who gave birth within the past year reported receiving an STI diagnosis during pregnancy⁵⁶ while 24.6% of FSWs in Port Elizabeth, South Africa who had any birth experience were initially diagnosed with HIV during pregnancy.⁵¹ Finally, across three cities in Papua New Guinea, 8.3%–19.1% of FSWs who were screened for syphilis during their last pregnancy received a syphilis diagnosis.⁵⁸

Three publications also reported the prevalence of other pregnancy and labor complications.^38,47,56 In Dhaka, Bangladesh, the most prevalent complication among FSWs was severe weakness (60.7%), followed by excessive bleeding (41.0%), blurry vision (26.2%), headache (24.6%), edema (24.6%), severe anemia (16.4%), and lower abdominal pain (14.8%).⁵⁶ Among FSWs in Madhya Pradesh, India, weakness was also the most commonly reported pregnancy complication (19.7%), whereas a smaller proportion of women reported excessive bleeding (14.1%), excessive pain (2.8%), and edema (1.4%).⁴⁷ Among adolescent FSWs in Seattle, Washington, the most prevalent complication was pregnancy-induced hypertension (15.0%), followed by premature rupture of membranes (7.0%), placental abruption (2.0%), and amnionitis (2.0%).³⁸

Delivery and PNC utilization

Five publications reported data on the proportion of FSWs who had skilled birth personnel present during childbirth (Table 2).^{38,47,48,52,56} The highest proportion of FSWs who had a skilled presence during delivery was reported in Port Elizabeth, South Africa, where 100% of participants with young children responded that they delivered at a healthcare facility.⁵² In contrast, 50.7% of FSWs in Madhya Pradesh, India, reported having skilled personnel attend a birth, as home births and traditional attendants were more commonly reported.⁴¹

One publication reported data on PNC utilization. Among FSWs with recent birth experience in Dhaka, Bangladesh, more than 50% of women surveyed received no amount of postnatal care, while 23% had two or more PNC contacts.⁵⁶

One publication reported data on the receipt of breastfeeding counseling. This qualitative study based in Mumbai, India, reported that few FSWs discussed receiving breastfeeding counseling from medical providers during in-depth interviews.⁴³ In addition, among FSWs that did report counseling experience, they described the guidance they received as primarily focused on discouraging breastfeeding. This was due to providers’ concerns about mother-to-child transmission of HIV and women’s ability to maintain an adequate milk supply.

Barriers to MHS

Six publications reported data on barriers that impacted FSWs’ utilization of MHS.^44,50
–54 These factors are presented in Table 3 and organized by relevant phases of the Three Delays model.

Table 3.

Barriers to maternal health services.

Factor	Findings	Citation(s)
Phase I: Delays in decision to seek care
Late pregnancy discovery	Participants reported late discoveries of unintended pregnancies in the second or third trimesters, making it impossible to initiate ANC earlier	Parmley et al.⁵¹ Shewale and Sahay⁵⁰
Unwanted pregnancy	Participants discussed avoiding ANC due to negative feelings about their unwanted pregnancies	Dewey et al.⁴⁴ Parmley et al.⁵¹
Unwanted pregnancy	Participants discussed avoiding care to either facilitate pregnancy loss or to prevent medical professionals from confirming a pregnancy and barring women’s access to potential abortifacients	Dewey et al.⁴⁴ Parmley et al.⁵¹ Shewale and Sahay⁵⁰
Past experiences with MHS	Participants reported delaying ANC initiation because of discontentment with prior experiences caused by long wait-times and/or poor treatment by clinic staff	Parmley et al.⁵¹
	Participants reported that prior pregnancies and past experiences with ANC made them feel more comfortable delaying care with a current pregnancy	Parmley et al.⁵¹
Perceptions of maternal health care	Participants believed seeking ANC before the fourth or fifth month of pregnancy was too early	Parmley et al.⁵¹
	Several participants perceived ANC attendance as “annoying” and believed the information provided at visits was repetitive	Parmley et al.⁵¹
Perceptions of the health care system	Participants felt that the health care system worked against pregnant women who use substances and engage in sex work. This contributed to care avoidance.	Dewey et al.⁴⁴
Internalized stigma toward sex work and pregnancy	Participants reported avoiding ANC due to feelings of guilt, shame, and embarrassment in regards to engaging in sex work and/or using substances while pregnant	Parmley et al.⁵¹ Dewey et al.⁴⁴ Shewale and Sahay⁵⁰
External stigma toward sex work and pregnancy	Participants discussed avoiding ANC to prevent disclosure to family members, health care providers, and/or clients who may react negatively	Parmley et al.⁵¹ Dewey et al.⁴⁴ Shewale and Sahay⁵⁰
Fear	Participants discussed FSWs avoiding ANC due to a fear of HIV diagnoses	Parmley et al.⁵¹
	Participants reported further delaying or sporadically attending ANC due to fears of clinic staff reacting negatively about their limited care engagement	Parmley et al.⁵¹
	Participants discussed avoiding ANC because of the fear that clients or neighbors would discover their pregnancies	Shewale and Sahay⁵⁰
	Participants who were considering pregnancy termination reported avoiding ANC and medical confirmation of pregnancy due to fear of potential legal consequences of termination	Shewale and Sahay⁵⁰
Phase II: Delays in arrival to a facility
Travel constraints	A participant reported missing ANC appointments due to the distance of a clinic and her inability to afford transportation fares	Parmley et al.⁵¹
Phase III: Delays in the provision of adequate care
Discrimination against single/unmarried women	Several participants were told they must bring a male partner to access ANC and antenatal HIV screening	Beckham et al.⁵³
	Several health centers had postings stating that care would be denied if partners were not brought during an initial ANC visit	Shewale and Sahay⁵⁰ Beckham et al.⁵³
	28% of participants (54/192) were asked to bring a male partner to ANC; 2/54 were fully denied services because they lacked a male partner	Rwema et al.⁵²
	85.35% of participants (233/273) were told to bring a male partner to ANC; 38/232 did not access ANC because of this	Beckham et al.⁵⁴
Providers’ perceptions of FSWs’ needs	Participants reported that health care providers assumed all FSWs were living with HIV. This would cause pregnant FSWs to be redirected to HIV-related services rather than ANC	Beckham et al.⁵³
Provider stigma against sex workers	Participants discussed being “separated out” from other pregnant women and feeling the need to present themselves “like a mother” to receive adequate care	Beckham et al.⁵³
Provider stigma against sex workers	Participants reported experiencing poor treatment by health care providers and having their sex work and/or substance use disclosed to others by staff	Dewey et al.⁴⁴

ANC: antenatal care; MHS: maternal health service(s); HIV: human immunodeficiency virus.

Factors influencing delays in the decision to seek care (phase I)

Based on data reported in three publications, several factors were identified that contribute to delays in FSWs’ decisions to seek MHS.^44,50,51 Late pregnancy discovery was one such factor and FSWs in South Africa and India described how this impacted their decisions to seek care during in-depth interviews.^50,51 Several FSWs reported discovering unintended pregnancies only when their “stomachs” were visibly enlarged during the second or third trimesters. As a result, the women could not decide to seek ANC earlier in their pregnancies as they lacked knowledge of their condition.

A pregnancy being unwanted was another factor identified as contributing to delays in the decision to seek care. During in-depth interviews, FSWs in South Africa and the United States described feeling distraught when they discovered they were pregnant.^44,51 These women spoke of avoiding ANC because it served as a reminder of their unwanted pregnancies. Some women also reported engaging in more substance use to cope with their situation, harm themselves, and/or to facilitate pregnancy termination.^44,51 In these situations, ANC was delayed or refused to prevent any medical intervention. Similarly, in India, FSWs with unwanted pregnancies described avoiding ANC and medical confirmation of pregnancy due to concerns that this would impede their access to medications or local remedies that were believed to induce abortions.⁵⁰

A third identified factor was FSWs’ prior experiences with MHS. Data from in-depth interviews with FSWs in South Africa indicated that some women delayed or avoided ANC during subsequent pregnancies due to prior experiences at clinics where wait-times were long and/or maltreatment by providers occurred.⁵¹ In addition, some FSWs described seeking fewer ANC contacts during more recent pregnancies because they believed the knowledge acquired from previous pregnancies was sufficient.⁵¹

Other factors that were identified from reviewed publications include FSWs’ perceptions of maternal health care and the health care system generally. For example, in South Africa, interviews with FSWs revealed that some women decided to delay ANC until after the first trimester due to the perception that ANC initiation before the fourth or fifth month was too early.⁵¹ In addition, other FSWs described deciding to delay care because they perceived ANC as “annoying” due to the repetitiveness of information provided by clinic staff.⁵¹ In terms of perceptions of the health care system, qualitative data from FSWs who use drugs in the United States highlighted how some women perceived the system as “working against” them.⁴⁴ These women viewed the health care system as prioritizing the removal of children from a mother’s custody, regardless of mothers’ circumstances or efforts. This perception contributed to care avoidance during pregnancy and the postpartum period.

Internalized and external stigma toward sex work were also identified as factors relevant to phase I delays for FSWs in South Africa, the United States, and India.^44,50,51 In interviews, FSWs described feeling embarrassed, ashamed, and/or guilty that they engaged in sex work during pregnancy.^44,51 These feelings influenced women’s decisions to seek care as they did not want to disclose information about their sex work and/or pregnancy to providers, partners, or family members.^44,51 In addition, experiencing and anticipating stigma from family members, clients, and health care workers were cited by FSWs as reasons for avoiding or delaying the use of MHS.^44,50,51

A final factor identified as relevant to phase I delays was fear. For example, in South Africa, FSWs reported delaying or completely avoiding ANC during pregnancy because they feared receiving HIV diagnoses, particularly when they were experiencing potential symptoms.⁵¹ FSWs also described feeling fear about clinic staff having negative reactions to their limited engagement with ANC. This fear discouraged women from initiating ANC and/or consistently attending visits.⁵¹ Fear was also identified as a prominent factor for FSWs in India, where pregnant FSWs working in rural areas described avoiding health facilities due to concerns that clients or neighbors may recognize them and discover their pregnancies.⁵⁰ In addition, for FSWs who were considering pregnancy termination, ANC and general obstetric care were also avoided due to a fear of possible legal consequences if health care workers suspected the women were seeking an abortion and/or had prior abortions.⁵⁰

Factors influencing delays in physically accessing facilities (phase II)

Only one publication reported data relevant to phase II delays.⁵¹ During interviews with FSWs in South Africa, at least one woman indicated that the distance of an ANC clinic and the cost of transportation were factors that impacted her ability to engage with MHS.⁵¹

Factors influencing delays in the provision of adequate care (phase III)

Results from five publications illustrated three factors that contribute to delays in the provision of adequate maternal health care for FSWs. One factor that was identified in four publications was discrimination against single/unmarried women.^50,52
–54 During in-depth interviews, FSWs in both India and Tanzania discussed encountering health care workers and clinics that required a male partner’s attendance at appointments for pregnancy-related services.^50,53 Women who failed to adhere to this policy described being denied ANC and antenatal HIV/STI screenings. Further, in Tanzania, it was reported that some health centers posted announcements that explicitly stated pregnant women would be denied care if a male partner was not brought to an initial visit.⁵³ In addition, results from two quantitative, survey-based publications also demonstrated the impact of such discrimination on FSWs’ ability to receive adequate maternal health care. In another sample of FSWs based in Tanzania, 85.4% of participants reported being told to bring a male partner to ANC visits, and 16.3% of these women did not access ANC because of this policy.⁴⁷ In South Africa, 28% of FSWs described being asked to bring a male partner to ANC, whereas 3.7% of these women reported being fully denied care when a male partner did not accompany them.⁵²

A second factor that was identified as facilitating delays in the provision of adequate care was health care workers’ perceptions of FSWs’ needs. During interviews, several FSWs in Tanzania reported that health care workers would immediately assume sex workers were living with HIV and needed to be redirected to HIV treatment centers. This caused pregnant FSWs who disclosed their sex work to face delays in accessing ANC as clinic staff would insist that women seek HIV-related care before addressing other health needs.⁵³ Relatedly, a third factor identified as relevant to phase III delays was health care workers’ stigma against sex workers. In the same sample of FSWs from Tanzania, participants recalled being “separated out” from other pregnant women while seeking ANC because they were viewed as “deviant” and living with HIV by staff. Because of this, participants described attempting to dress “with respect” and “like a mother” so they could receive the same treatment as others attending the clinic.⁵³ In the United States, FSWs similarly reported experiencing differential and negative treatment by health care workers who knew they engaged in sex work and used substances, making it more difficult for women to receive timely, respectful, and appropriate care.⁴⁴

Discussion

This review is the first to focus on the maternal health of FSWs—a subject that has been historically overlooked despite the high proportion of FSWs who experience pregnancy and have children. A total of 18 publications were identified that reported results on ANC utilization, pregnancy and labor complications, delivery care and PNC utilization, and barriers to MHS for FSWs.

The findings from this review highlight several limitations of the existing literature and can inform priorities for future research on the subject. For example, many of the included studies collected data on maternal health measures as a secondary outcome and did not specifically recruit participants with pregnancy or birth experience. As such, results on maternal health outcomes were primarily descriptive and often derived from relatively small sample sizes. Further, in quantitative studies, there was limited investigation of how factors such as age, relationship status, type of sex work, income, and substance use impacted maternal health outcomes and utilization of MHS. In considering these limitations, more research is needed that specifically focuses on investigating the maternal health of FSWs and the sociodemographic, occupational, and behavioral factors that may be associated with related outcomes. Such work would help generate more accurate estimates of the prevalence of MHS utilization and maternal health complications for FSWs while also improving our understanding of characteristics associated with poor maternal health outcomes and/or low engagement with MHS—information that could facilitate the development of targeted interventions for FSWs who are identified as particularly vulnerable.

Another limitation of the existing literature is the heterogeneity in how different maternal health outcomes are measured and reported. This was particularly evident in measures on FSWs’ number of ANC contacts and timing of ANC initiation. This heterogeneity enhances the difficulty of making comparisons across populations and impedes the pooling of different studies’ results for further analysis. To promote more consistency in outcome definitions, future research on the maternal health of FSWs could consider utilizing the World Health Organization’s recommendations for optimal MHS engagement to guide outcome measurement and reporting. This would involve the documentation of the following outcomes: initiation of ANC within the first 12 weeks of pregnancy, engagement in at least eight ANC contacts, receipt of antenatal screening for HIV and locally relevant STIs, presence of skilled health personnel during delivery, engagement in at least four PNC contacts in the 42 days after birth, and receipt of breastfeeding counseling.^13
–15

A third limitation of the current body of research is the dearth of research on FSWs’ engagement in PNC and breastfeeding counseling. Only two studies were identified that reported data on these outcomes despite the importance of such care in supporting the health of FSWs and their infants.^49,56 The majority of maternal deaths worldwide occur during the postnatal period when women experience a higher risk of hemorrhage, obstetric infections, and complications from pregnancy-induced hypertension.⁵⁹ FSWs may be particularly vulnerable to postnatal morbidity and mortality as previous research has demonstrated some women return to sex work within a week of childbirth.^49,60 Because PNC aids in the early detection of complications like uterine infections, cervical injuries, and hemorrhaging, postpartum women who return to sex work soon after birth would greatly benefit from such services.^15,59 In addition, beyond general PNC, breastfeeding counseling is also of critical importance to FSWs as they experience a disproportionately high burden of HIV.^29,61,62 Thus, the provision of comprehensive breastfeeding counseling that provides FSWs with information on breastfeeding options and current health guidelines could help reduce the incidence of vertical HIV transmission among FSWs and their children. Future studies assessing the maternal health of FSWs should not only focus on ANC but also gather data on FSWs’ engagement with any PNC, engagement with breastfeeding counseling, breastfeeding prevalence (for both exclusive and non-exclusive breastfeeding), and the length of time between birth and returns to sex work (if applicable). Overall, improving our knowledge on FSWs’ engagement with PNC and breastfeeding counseling—as well as the potential barriers they face to such services—can inform the structure and scale of interventions that improve access to care and help address postnatal morbidity and mortality in this population.

A final limitation of the existing literature that this scoping review highlights is the lack of data related to the quality of MHS that FSWs receive. Indeed, the majority of quantitative studies primarily reported outcomes related to whether services were accessed with limited investigation into whether the care received was acceptable and appropriate. Improving our understanding of the quality of MHS that FSWs receive across different contexts is critical given that factors such as negative prior experiences with MHS, negative perceptions of clinics’ operations, and stigmatization from clinic staff were identified as prominent barriers to MHS among FSWs.^44,50,51,53 While there remains no consensus on optimal indicators of maternal health care quality, future studies could measure outcomes such as FSWs’ satisfaction with services rendered and the extent to which potential barriers to MHS—including long wait-times, cost, clinic hours, and discrimination by clinic staff—were experienced by participants.⁶³ Capturing such data would be essential for informing, evaluating, and improving upon efforts to increase MHS utilization among FSWs.

Public health and clinical care implications

Beyond insights about the current state of the literature on FSWs’ maternal health, the findings from this review also demonstrate that a large proportion of FSWs are not engaging in the full, recommended continuum of maternal health care. Indeed, in some study locations, more than 40% of surveyed FSWs reported not accessing services such as ANC, PNC, or antenatal HIV/STI screening at any point during a prior pregnancy.^{41,47,52,55,56} Troublingly, such low levels of engagement with MHS are happening despite increased efforts and investments in improving access to maternal health care worldwide for marginalized women.^8,13 As such, there is an urgent need to address existing barriers to MHS for FSWs.

This review’s synthesis of data on factors impacting MHS utilization reveals several potential avenues for intervention. For example, factors that contribute to delays in FSWs’ decisions to seek care (phase I delays) were the most frequently identified in the existing literature, indicating that intervening at this stage could have a substantial impact on improving MHS utilization. Two factors that are particularly amenable to general intervention are the late discovery of pregnancy and the incidence of unwanted pregnancies. The prevalence of these factors could be reduced by improving FSWs’ access to facility-based and self-administered pregnancy testing. Existing research has demonstrated that, despite the clear utility of pregnancy testing, a minority of sexual and reproductive health programs that serve FSWs offer this service.⁶⁴ Addressing this gap and expanding the provision of pregnancy testing resources for FSWs could increase the likelihood of earlier pregnancy identification and allow FSWs to seek pregnancy termination services if desired. Relatedly, reducing barriers to contraceptives and pregnancy termination services for FSWs would also help address the incidence of unwanted and/or unintentional pregnancies. Studies have reported wide variation in FSWs’ use of different contraceptives and identified various barriers to contraceptive use including costs, inconvenient or disorganized sexual health clinics, and misinformation about contraceptives’ effects.^50,65
–67 Addressing these barriers through educational campaigns, subsidized medical services, and/or improvements in clinic operations could further help prevent the occurrence of phase I delays. In addition, very few facility-based programs that exclusively serve FSWs offer pregnancy termination services and many countries restrict access to abortions.⁶⁴ Thus, efforts to expand pregnancy termination services, repeal existing restrictions, and advocate against further restrictions are desperately needed.

FSWs’ decisions to seek MHS may also be impacted by the criminalization of sex work, though this was not explicitly identified as a barrier by participants in studies included in this review. Indeed, while there is substantial variation in the legality of sex work across the world, prior research in several different countries has demonstrated that fear of law enforcement and experiences with police harassment have a negative impact on sex workers’ access to other forms of health care.^26
–28 Given this, further investigation is warranted into how the legal context of sex work in a country impacts FSWs’ decisions to pursue MHS. In addition, many of the barriers identified in this review that contribute to phase I delays—such as external stigma, internalized stigma, negative perceptions of the health care system, and fear of disclosure—are likely bolstered by the criminalization of sex work.⁶⁸ Thus, efforts to decriminalize sex work and prevent police harassment may be essential to better supporting pregnant and postpartum FSWs’ access to MHS.

Several factors that influenced the occurrence of delays in FSWs’ receipt of adequate care (phase III delay) are also amenable to public health intervention. For example, discrimination against single/unmarried women at antenatal clinics was identified in multiple publications as a barrier to ANC.^50,52
–54 While such policies may stem from public health recommendations that encourage male engagement with ANC and/or partnered testing for HIV, they can restrict FSWs’ access to necessary care. As such, efforts are needed to clarify to clinic staff that current public health guidelines do not necessitate the establishment of restrictive policies and to emphasize that enacting such policies has health consequences.

Other factors that must be addressed to prevent delays in FSWs’ receipt of appropriate maternal health care are health care workers’ perceptions of FSWs and the stigma against FSWs. For example, providers’ perceptions of FSWs’ health needs have led women to be redirected from antenatal clinics to HIV-focused clinics, delaying their access to timely ANC.⁵³ Given this, one potential intervention for preventing delays in care could be to improve the integration of HIV-related services and MHS in facilities that cater to pregnant and postpartum women. This type of integrative service delivery has been implemented before in various sub-Saharan African countries and could help decrease the incidence or severity of phase III delays.^30,69 In addition, designing and implementing educational interventions for clinic staff that highlight the importance of MHS for FSWs and emphasize FSWs’ identities as mothers could also help address reductive perceptions of their health needs.

In general, there is a dearth of clinical and national guidelines that offer recommendations on the specific medical needs of FSWs, and especially pregnant and postpartum FSWs. Indeed, the few guidelines that have been published on improving sex workers’ health have primarily focused on the prevention and treatment of HIV/STIs. Nevertheless, these existing guidelines emphasize and provide recommendations related to empowering communities of sex workers, addressing structural violence and barriers to care, combatting stigma and discrimination among service providers, and redressing human rights violations experienced by sex workers.^70,71 Creating and disseminating similar guidelines specifically related to FSWs’ maternal health and optimal delivery of MHS could further help maternal health facilities establish more tailored services for FSWs, enhance providers’ confidence in delivering appropriate and acceptable care, address stigmatizing views and clinic practices, and emphasize the importance and relevance of MHS for FSWs. Further, given the limited attention FSWs’ maternal health has received, they should be explicitly recognized as a key population in future maternal health literature and guidelines, along with the specific barriers they face to accessing MHS. Doing so would bring greater attention to FSWs’ maternal health and highlight the importance of efforts to research and evaluate the extent to which current initiatives to improve maternal health are impacting this population. Critically, such guidelines and accompanying recommendations should be informed by future, more comprehensive investigations into FSWs’ maternal health and the factors affecting this, as well as the perspectives and expertise of local communities of sex workers and programs/organizations that support sex workers.

A final potential avenue for public health action that could address both delays in FSWs’ decisions to seek care and their receipt of adequate care is the establishment of more programs and facilities dedicated to specifically serving FSWs. As highlighted in this review, many FSWs report their fear of and prior experiences with maltreatment, stigmatization, and confidentiality breaches as barriers to MHS at clinics serving the general population.^44,50,51,53 In contrast, prior studies evaluating the impact of sex worker-focused facilities/programs in South Africa, Mozambique, and India have demonstrated that FSWs report high satisfaction with the care they receive and that they perceive these facilities to be more efficient, welcoming, and effective at addressing their needs.^72–75 Further, FSWs have reported that the environment created by these facilities/programs helps women feel more respected, promotes honesty between providers and patients, and enhances women’s confidence that their privacy will be protected.^73–75 Sex-worker-specific facilities/programs can also be tailored to the needs of local FSWs in regards to optimal hours of operation and locations of service delivery—factors that would make services more accessible by accommodating FSWs’ typical working hours and further promoting FSWs’ privacy when seeking care. But, concerningly, the majority of existing facilities/programs for FSWs rely on support from international donors with limited direct government funding, and many programs are implemented as a part of research activities.^64,68 As a result, the long-term sustainability of programs is often uncertain—something which threatens the health of FSWs who rely on such programs and can undermine trust in health services.⁶⁴ Thus, if additional facilities/programs are established to support the general and maternal health of FSWs, it is of critical importance that stable funding mechanisms and implementation strategies are identified to ensure these programs have longevity and scalability.

Of note, while there are many examples of sex worker-focused programs that offer HIV/STI-related services, there are few that offer more comprehensive health services such as pregnancy testing, contraceptive services, pregnancy termination, ANC, or PNC.⁶⁴ Further, there are even fewer programs that focus on supporting pregnant and postpartum FSWs’ broader needs such as housing stability, food security, or protection from violence. One example of a program that does offer such comprehensive services is Sheway—a Vancouver-based program that supports street-involved pregnant and postpartum women, many of whom are engaged in sex work.^76,77 The program provides a myriad of resources and services including comprehensive ANC and PNC, substance use disorder treatment, nutritional support, access to toiletries, advocacy on housing and legal issues, recreational programming, and referrals for ongoing community-based support.⁷⁴ Evaluations of the program have demonstrated that participating women experience improved maternal and child health outcomes and increased engagement in medical care, demonstrating the positive impact such services can have for FSWs.^76–78 Further, several components of the program have been identified as particularly valuable for reaching, retaining, and generally supporting their participants including assistance with women’s practical needs like transportation and food, provision of multidisciplinary services that promote women’s autonomy in choosing which services suit their current needs, and assistance with meeting child protection standards of care.⁷⁴ Overall, given the high incidence of pregnancy and the prevalence of motherhood among FSWs, expanding programs that are modeled after organizations like Sheway could be extremely effective in improving FSWs’ maternal health and addressing barriers related to phase I and phase III delays.

Limitations and strengths

This review has several limitations. First, as is typical of scoping review methodology, the quality of studies was not formally evaluated. Second, because there was no intention to pool study results, studies were included that had heterogeneous outcome definitions, making comparative assessments between studies more difficult. Third, given the complex, dynamic nature of sex work’s legal status in many countries over time, whether sex work was criminalized and to what extent in locations of included studies was not documented in this review, though such factors likely impact service utilization and contribute to heterogeneity in outcomes across settings. Finally, this review excluded data from non-peer-reviewed publications, gray literature, and unpublished works. While this was done to enhance the potential quality of included studies, this could have led to the exclusion of data that may have provided more insight into FSWs’ maternal health.

Still, there are several strengths of the methods and approach used in this review. First, both quantitative and qualitative studies were included, allowing for a more comprehensive overview of the existing literature. In addition, by assessing outcomes that cover the full continuum of recommended maternal health care, this review not only offers insight into the extent of FSWs’ engagement with different MHS but also highlights gaps in the existing research such as the limited investigation of PNC access for FSWs. Further, this review’s use of the Three Delays model to synthesize and report data on factors impacting MHS utilization represents another strength since this approach lends itself to the identification of practical points of intervention and public health action that target both women who use MHS and providers who offer them.¹⁷

Conclusion

To our knowledge, this is the first literature review to focus on FSWs’ maternal health and utilization of MHS. The findings of this review demonstrate that FSWs face a myriad of barriers to MHS and low engagement with the full continuum of maternal health care. As global efforts to reduce inequities in maternal health continue, it is clear that FSWs must be a target for tailored intervention development and resource provision. This is critical since, even with improvements in access to contraceptives, pregnancy termination services, and sexual health resources, there will likely always be a substantial proportion of FSWs who become pregnant and/or desire to be pregnant. Thus, continuing to develop our knowledge on FSWs’ maternal health and the factors that generate delays in their access to adequate services is essential.

Supplemental Material

sj-docx-1-whe-10.1177_17455057231206303 – Supplemental material for Maternal health and maternal health service utilization among female sex workers: A scoping review

Supplemental material, sj-docx-1-whe-10.1177_17455057231206303 for Maternal health and maternal health service utilization among female sex workers: A scoping review by Brandi E Moore, Lauren Govaerts and Farzana Kapadia in Women’s Health

Footnotes

Acknowledgements

The authors thank Hope Lappen, life science librarian, at New York University, for her support in developing the search strategy and specific database search terms. They also thank Dr. Danielle Ompad for her feedback during the initial stages of this review.

Declarations

ORCID iD

Brandi E Moore

Supplemental material

Supplemental material for this article is available online.

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