Health of female sex workers and their children: a call for action
Authors: Brian Willis, Katherine Welch, Saki Onda
Journal: The Lancet Global Health (2016)

Two very critical health and human rights issues related to sex work have been neglected globally: maternal morbidity and mortality among female sex workers and the health and wellbeing of their children. It is time to recognise the need for, and right to, maternal and child health services for female sex workers and their children. Many female sex workers have risk factors for maternal morbidity and mortality, especially HIV-related mortality and complications and death from unsafe abortions. However, little is known about the global impact of maternal morbidity and mortality on female sex workers compared with HIV and violence against them.1Baral S Beyrer C Muessig K et al.Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis.Lancet Infect Dis. 2012; 12: 538-549Summary Full Text Full Text PDF PubMed Scopus (842) Google Scholar, 2Deering KN Amin A Shoveller J et al.A systematic review of the correlates of violence against sex workers.Am J Public Health. 2014; 104: e42-e54Crossref PubMed Scopus (287) Google Scholar Female sex workers in sub-Saharan Africa are most likely have the highest risk of maternal morbidity and mortality because of their high rates of HIV, unintended pregnancies, and abortions, along with the region's high maternal mortality rate.1Baral S Beyrer C Muessig K et al.Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis.Lancet Infect Dis. 2012; 12: 538-549Summary Full Text Full Text PDF PubMed Scopus (842) Google Scholar, 3Schwartz S Papworth E Thiam-Niangoin M et al.An urgent need for integration of family planning services into HIV care: the high burden of unplanned pregnancy, termination of pregnancy, and limited contraception use among female sex workers in Côte d'Ivoire.J Acquir Immune Defic Syndr. 2015; 68: S91-S98Crossref PubMed Scopus (66) Google Scholar, 4Sutherland EG Alaii J Tsui S et al.Contraceptive needs of female sex workers in Kenya—a cross-sectional study.Eur J Contracept Reprod Health Care. 2011; 16: 173-182Crossref PubMed Scopus (55) Google Scholar In other regions, female sex workers are likely to be at higher risk of maternal morbidity and mortality than are other women, resulting in substantial health disparities. Globally, the majority of female sex workers are mothers, raising millions of children (table). Many of these children are at high risk of HIV, congenital syphilis, fetal alcohol syndrome, physical and sexual violence, and tuberculosis.5Shahmanesh M Wayal S Cowan F Mabey D Copas A Patel V Suicidal behavior among female sex workers in Goa, India: the silent epidemic.Am J Public Health. 2009; 99: 1239-1246Crossref PubMed Scopus (63) Google Scholar, 6Majid N Bollen L Morineau G et al.Syphilis among female sex workers in Indonesia: need and opportunity for intervention.Sex Transm Infect. 2010; 86: 377-383Crossref PubMed Scopus (15) Google Scholar, 7Chersich MF Bosire W King'ola N Temmerman M Luchters S Effects of hazardous and harmful alcohol use on HIV incidence and sexual behaviour: a cohort study of Kenyan female sex workers.Global Health. 2014; 10: 22Crossref PubMed Scopus (61) Google Scholar, 8Beard J Giemba G Brooks MI et al.Children of female sex workers and drug users: a review of vulnerability, resilience and family-centered models of care.J Int AIDS Soc. 2010; 13: S6Crossref PubMed Scopus (34) Google Scholar However, there are few studies on children of female sex workers and none include data on their HIV rates or causes of death.8Beard J Giemba G Brooks MI et al.Children of female sex workers and drug users: a review of vulnerability, resilience and family-centered models of care.J Int AIDS Soc. 2010; 13: S6Crossref PubMed Scopus (34) Google ScholarTableSex workers who are mothers and their childrenProportion of female sex workers who are mothersProportion with more than two childrenCôte d'Ivoire3Schwartz S Papworth E Thiam-Niangoin M et al.An urgent need for integration of family planning services into HIV care: the high burden of unplanned pregnancy, termination of pregnancy, and limited contraception use among female sex workers in Côte d'Ivoire.J Acquir Immune Defic Syndr. 2015; 68: S91-S98Crossref PubMed Scopus (66) Google Scholar68·5% (319/466)15·2% had ≥3 living childrenKenya4Sutherland EG Alaii J Tsui S et al.Contraceptive needs of female sex workers in Kenya—a cross-sectional study.Eur J Contracept Reprod Health Care. 2011; 16: 173-182Crossref PubMed Scopus (55) Google Scholar82·9% (N=597)*n not provided in study.NAKenya7Chersich MF Bosire W King'ola N Temmerman M Luchters S Effects of hazardous and harmful alcohol use on HIV incidence and sexual behaviour: a cohort study of Kenyan female sex workers.Global Health. 2014; 10: 22Crossref PubMed Scopus (61) Google Scholar80·2% (321/400)8·4% had ≥4 childrenIndia5Shahmanesh M Wayal S Cowan F Mabey D Copas A Patel V Suicidal behavior among female sex workers in Goa, India: the silent epidemic.Am J Public Health. 2009; 99: 1239-1246Crossref PubMed Scopus (63) Google Scholar80·7% (254/325)NAIndonesia6Majid N Bollen L Morineau G et al.Syphilis among female sex workers in Indonesia: need and opportunity for intervention.Sex Transm Infect. 2010; 86: 377-383Crossref PubMed Scopus (15) Google Scholar68·7% (2970/4324)NAMexico11Morris MD Case P Robertson AM et al.Prevalence and correlates of 'agua celeste' use among female sex workers who inject drugs in Ciudad Juarez, Mexico.Drug Alcohol Depend. 2011; 117: 219-225Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar93·3% (295/316)NAData are % (n/N) unless otherwise specified. n=those with children. N=total participants.* n not provided in study. Open table in a new tab Data are % (n/N) unless otherwise specified. n=those with children. N=total participants. In view of the lack of data on these issues, we are convening meetings with female sex workers in South Asia, sub-Saharan Africa, North Africa, North and South America, Europe, and Southeast Asia to discuss their situations during pregnancy and childbirth and their children. Their comments will be presented at the Fourth Women Deliver Conference (May 16–19). During the initial meetings, female sex workers have reported important maternal health issues (panel).PanelIssues reported by female sex workers during the initial meetings•In many communities mothers enter sex work primarily to feed their children.•Most female sex workers become pregnant and many have unsafe abortions resulting in morbidity and mortality. In North Africa, there were several reports of complications and deaths after taking a pill purchased on the street or "using a plastic stick."•Pregnant female sex workers often experience barriers to antenatal care and delivery, including discrimination by health-care workers who have "beaten" and "humiliated" them and treated them "worse than other pregnant women".•In several meetings, women reported that pregnant female sex workers are subjected to violence by clients and some are murdered.•Many pregnant female sex workers must work until they go into labour and some deliver in their home, bars, or street.•Several deaths of pregnant female sex workers have been reported, including the death of a female sex worker who gave birth in a latrine; her infant also died. Other female sex workers reported the death of a colleague from bleeding due to "negligence" of the medical staff. One group of female sex workers reported that 20% of the pregnant women in their community had died during pregnancy or childbirth in the past 3 years.•Many female sex workers must return to work within days or weeks after giving birth, limiting their opportunities to breastfeed.•Suicides among pregnancy sex workers were reported along with antenatal and postpartum depression, indicating these are both risks for many female sex workers.•Many female sex workers must leave their children alone overnight. Infants and children are often given cough syrup and other medicines to make them sleep. In other cases, mothers must leave their children in substandard childcare facilities where they reportedly receive less care than other children, are injured when unsupervised, and become ill from unhygienic food. Mothers also pay other sex workers and other people to care for their children but some female sex workers have no options and must take their children with them to meet clients. •In many communities mothers enter sex work primarily to feed their children.•Most female sex workers become pregnant and many have unsafe abortions resulting in morbidity and mortality. In North Africa, there were several reports of complications and deaths after taking a pill purchased on the street or "using a plastic stick."•Pregnant female sex workers often experience barriers to antenatal care and delivery, including discrimination by health-care workers who have "beaten" and "humiliated" them and treated them "worse than other pregnant women".•In several meetings, women reported that pregnant female sex workers are subjected to violence by clients and some are murdered.•Many pregnant female sex workers must work until they go into labour and some deliver in their home, bars, or street.•Several deaths of pregnant female sex workers have been reported, including the death of a female sex worker who gave birth in a latrine; her infant also died. Other female sex workers reported the death of a colleague from bleeding due to "negligence" of the medical staff. One group of female sex workers reported that 20% of the pregnant women in their community had died during pregnancy or childbirth in the past 3 years.•Many female sex workers must return to work within days or weeks after giving birth, limiting their opportunities to breastfeed.•Suicides among pregnancy sex workers were reported along with antenatal and postpartum depression, indicating these are both risks for many female sex workers.•Many female sex workers must leave their children alone overnight. Infants and children are often given cough syrup and other medicines to make them sleep. In other cases, mothers must leave their children in substandard childcare facilities where they reportedly receive less care than other children, are injured when unsupervised, and become ill from unhygienic food. Mothers also pay other sex workers and other people to care for their children but some female sex workers have no options and must take their children with them to meet clients. Female sex workers also reported stillbirths and serious health problems among their children, including: neonatal deaths, low birthweight, prematurity, neonatal abstinence syndrome, behavioural and emotional problems, and discrimination at school. Additionally, many daughters of these sex workers are trafficked while other children are stolen and sold. We also discussed these issues with mothers who had been trafficked. They reported that many victims do not realise they are pregnant and do not receive antenatal care, whereas in other cases the pimps will not allow victims to access antenatal care. They also reported that most victims use drugs and alcohol while pregnant because "….in the life [you] can't be sober." Finally, we were told that pimps force pregnant victims to continue to have sex with clients because "pregnancy sells". Regarding their children, survivors reported that some die of sudden infant death syndrome, others are abused by pimps and witness pimps assaulting their mothers, and when the children enter school some have learning disabilities and anger problems. Failure to target maternal and child health services to female sex workers and their children results in preventable morbidity and mortality. It also undermines the Sustainable Development Goals and other global efforts, including eliminating paediatric HIV and congenital syphilis. We must also recognise the strong link between sex work and food insecurity related to global climate change, poverty, and conflicts.9Fielding-Miller R Mnisi Z Adams D Baral S Kennedy C "There is hunger in my community": a qualitative study of food security as a cyclical force in sex work in Swaziland.BMC Public Health. 2014; 14: 79Crossref PubMed Scopus (61) Google Scholar Some sex workers who are mothers use condoms less frequently than do other female sex workers.10Reed E Silverman JG Stein B et al.Motherhood and HIV risk among female sex workers in Andhra Pradesh, India: the need to consider women's life contexts.AIDS Behav. 2013; 17: 543-550Crossref PubMed Scopus (38) Google Scholar This is because they urgently need money to feed their children so they will engage in unprotected sex. In these situations addressing food insecurity among female sex workers and their children could be more effective in preventing HIV than simply providing condoms. Just as has been done for HIV, to address these issues we must partner with sex workers and sex worker organisations on maternal and child health, implement programmes specifically for pregnant sex workers and their children, and fund research on maternal and child health and sex work at the local, national, regional, and global levels.11Morris MD Case P Robertson AM et al.Prevalence and correlates of 'agua celeste' use among female sex workers who inject drugs in Ciudad Juarez, Mexico.Drug Alcohol Depend. 2011; 117: 219-225Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar The situation of many mothers who are sex workers or trafficking victims and their children violates their dignity and human rights and is unacceptable. We issue a call to action for maternal and child health for mothers who are sex workers and those who have been trafficked and their children. The right of these mothers to quality antenatal care and safe delivery and the right of their children to health, education, housing, and protection from discrimination and stigma, must be ensured. We declare no competing interests.