Pregnancy and Sexual Related Problems Among Women Living on the Street at Dire Dawa City, Ethiopia 2021

doi:10.21203/rs.3.rs-1206103/v1

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Research Article

Pregnancy and Sexual Related Problems Among Women Living on the Street at Dire Dawa City, Ethiopia 2021

https://doi.org/10.21203/rs.3.rs-1206103/v1

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Background: The problem of women and youths living on the street is a global phenomenon. It has created countless problems while they lived on the street. Women living on the streets are exposed to unwanted pregnancies and sexual-related problems as they are exposed to sexual exploitation, rape, and prostitution. It is a frequent observation to see women begging on the streets of major cities in Ethiopia having one or two babies by their sides. Besides they are less likely to benefit from basic reproductive health services as living in the poorest segment, delivering and caring for their children on the streets life. Little is known about the overall pregnancy and childbearing scenarios of street women and related health problems. This study will give a better in-depth understanding of the distressing and highly challenging problem among women on the street regarding pregnancy and related problems.

Objective: To explore pregnancy and sexual-related problems among women living on the street of Dire Dawa administration, Eastern Ethiopia 2021.

Methods: a community-based phenomenological qualitative study was conducted at Dire Dawa city. Data was collected from homeless women through focus group discussion and in-depth interviews using a semi-structured tool that has been translated into the local language, aided by a voice recorder. Then the collected data were translated and transcribed. Codes and themes were derived from the transcribed data using ATLAS to version 7. The final report was developed using a thematic narrative analysis method

Result: Women living on the street are more likely to experience physical abuse, sexual harassment, STI/HIV, unsafe sexual intercourse and unwanted pregnancy. As a result, the fate of this pregnancy is abortion which makes adolescents at high risk of getting health complications as most abortions are made in illegal and unsafe ways.

Conclusion: Unwanted pregnancy, STI, HIV, rape and unsafe abortion are the major concerns as it accompanied by their homelessness situation and abusive lifestyles. The regional health bureau needs to understand the extent of the problem and plan to organize an awareness creation program on STI/HIV, risk of pregnancy and SRH services.

women

street

pregnancy

sexual related

Living on the street is a severe societal, social and individual problem that is a rapidly growing aspect of developing countries due to some specific complicated social and family-related problems such as poverty, domestic violence, physical and sexual abuse, and HIV/AIDS. The street refers to places such as bus/car stops, outside of shops, around church/ mosque, minor and major roads of towns, parking lots, and other public places where youth/women attempt to make a living (1).

The problem of women and youths living on the street is a global phenomenon. It has created countless problems while they lived on the street. Shelter and street youth were at much greater risk of having ever been pregnant than were youth in households. They had the highest lifetime rates of pregnancy (48%), followed by youth residing in shelters (33%) and household youth < (10%) (2).

Women living on the streets are less likely to benefit from basic reproductive health services as living in the poorest segment, delivering and caring for their children out of streets life. Also, they are exposed to unwanted pregnancies and reproductive related problems as street people, girls and women, in particular, are exposed to sexual exploitation, rape and prostitution (3, 4)

This situation is far more aggravated when accompanied by homelessness as it accelerates susceptibility to the problem. Rape-induced Pregnancy rates among homeless women are much higher than the rates of the general population and seem to increase with the instability of their housing situation. It is a frequent observation to see women begging on the streets of major cities in Ethiopia having one or two babies by their sides (2, 3).

Very little is known about the overall social, psychological, economic, and health-related circumstances surrounding pregnancy practices of street women and related coping strategies. Even the little available researches do not show the full picture of the reality on the ground.

This research is, therefore, initiated to understand the pregnancy and sexual-related problems to generate relevant information that could help policymakers to design appropriate reproductive health programs for this disadvantaged segment of the population. This is the nagging issue which this study attempts to academically address.

Study setting and design

A qualitative Phenomenology study design was conducted in Dire Dawa city from December 21 / 2020 – February 21 / 2021. Dire Dawa is one of the two chartered cities in Ethiopia that lies in the eastern part of the nation, on the Dechatu River. There are 24 urban kebeles and 28 rural peasants associations under the chartered city.

Study population and sampling procedure

All reproductive age group women who are living on the street of Dire Dawa city was the source population. In addition, key informants from relevant organizations were included as a source population. Overall, we recruited a total of 14 IDI respondents and 3 FGD participants were included based on information saturation. A non-probability purposive sampling method was used to select women living on the street and the Snowball method was implemented to select key informants from the relevant organization which is PAD, LSAA and police station.

All Street women who have resided on the street of Dire Dawa city for a minimum of six months were taken as inclusion and mentally ill women who are unable to communicate were excluded from the study.

Data collection tool and procedures

Data was collected through focus group discussions and in-depth interviews. Both focus group discussions and in-depth interview was conducted using a semi-structured interview tool aided by a voice recorder and key-note keeping. Participants (both women living on the street and key informants) were interviewed once and the interviews will last about one hour. The interview was conducted at the shelter where the office provided them, a compound of PAD office as well as in major sites where they can be found (street corridor, church, mosque and their shelters). Focus groups discussions were carried out with 6 participants that lasts 80min -100min.

Data processing and analysis

Data were analyzed thematically using computer-assisted qualitative data analysis software Atlas.ti7. Qualitative data were transcribed by replaying the tape-recorded interview from in-depth interviews and focus group discussions. The text was carefully be read and similar ideas were organized together. Their inductive meanings were extracted and described in narratives using the well said verbatim of participants. The verbatim of participants was transcribed by the researcher and research assistants independently to confirm the reliability of the findings.

As Table 1 shows, A total of 32 women participants participated in this study; 18 respondents have participated in three focus group discussions; 6 participants in each focus group discussion while fourteen respondents participated in the in-depth interviews. (Table 1)

Inaddition, 3 key informants were participated from relevant organization. From the qualitative analysis of data, two major themes were derived. Participants interviewed and discussed about Pregnancy scenarios and Sexual related problems.

Table 1

Socio-demographic characteristics of respondents
Characteristics	IDI	FGD
Age
15 - 25	8	10
26 – 35	6	5
35 – 45	0	3
Education
Non-formal educated	9	12
Primary and below	5	6
Secondary and above	0	0
Religion
Muslim	9	13
Christian	5	5
Street life duration
1 – 10 year	6	6
11 – 20 year	7	11
21 - 30	1	1

1. Pregnancy scenario

Eleven of the 32 women were pregnant at the time of the interview (between eight and 30 weeks gestation) while the rest were those who have at least 2 previous pregnancy histories the past. This study found that the pregnancy rate among street women is very high including underage pregnancy among women living on the street and they become pregnant due to unwanted sexual intercourse. One of the participants mentioned her pregnancy history as below.

“I gave birth to my first baby a year ago at age of 15. A gang leader took me as his girl and used to force me to have sex with him whenever he wants. I used to get sick, vomit and get confused during pregnancy. I never went to the hospital. My labor was intense and he took me to the hospital as I was screaming in pain. I gave birth to my boy in just 7 months. …… Then 6 months back again I gave birth to my second boy. ……. Since the gang leader know it is not his baby, he stabbed me on my shoulder and another one on my left leg. Life is not fair. I never wanted to live life like this. But at age of 16, I am a mother of two.” (women from IDI participant)

Participants from IDI stated that the incompatibility of their lifestyle with the responsibility of raising a child on the street. The street pregnant teens emphasize as they are particularly faced countless hardship and danger on the streets. They lacked food, clean water and adequate health care, although these are very essential for pregnant women.

“I have delivered to one baby girl when I live on the street…..I am still raising my 8-month baby boy on the street and there are so many problems when you raise a baby on the street” she replied in sorrow….” I can’t get enough of my breast milk to breastfeed him because I am not eating enough food or drink. Let alone to wash and to be clean …..I can’t even get clean water to drink. You know …hmmmmm it is so hard to raise a kid here.” (women from IDI participant)

The study found that pregnancy was the main problem for street women and most of the time is was unwanted. as the discussant stated that women who live on the street are exposed to unwanted sexual intercourse followed by an unwanted pregnancy. In addition, FGD participants mentioned their pregnancy has become very challenging as it is accompanied by homelessness.

“There is a risk of having pregnancy on the streets. I was pregnant twice. First was unwanted at the age of 14. I was so young. Two of my street friends got pregnant at age of 14 and 15” (A woman from FGD participant)

“There are many of my friends who give birth on streets and raise them on the road. I am now 17 years old but I have 2 kids. So does my dear street friend. I did not understand anything about how a girl could now have pregnancy while having sex with all our troubles and uncomfortable lifestyles.”(A 17years old FGD participant)

On top of this participants mentioned that there is Sexual abuse and exploitation while in pregnancy is also one of the problems affecting the physical, social and psychological wellbeing of street teenagers during their pregnancy

“Young, homeless girls on the street often become pregnant. I am now pregnant in my 8th month. Despite all my attempts to stay safe on the street. I was raped and got pregnant by a stranger. So there is a risk and you cant avoid it. When street gang man knew I was pregnant with another man, he slapped me, punched me on my face and left me… Again I was raped on my 6th month pregnancy by 2 boys in the middle of the night. This life is so cruel. It is a scary place for any girl.” (women from IDI participant)

The reason for unwanted pregnancy found in the study was contraceptive issues like unavailability of contraceptives, inappropriate use of contraceptives and lack of information on the availability of the services as they don’t know where they can find the method. And some of them know where to find but the unfriendly service didn’t invite them to receive the care.

“It is very risky. I mean the risk of pregnancy is much higher on the street because of the unsafe sex here and lack of awareness among the youth and adolescents. We don’t know where to find protection for pregnancy besides, even condom is expensive to buy. Very little children like 15 and 16 years of age are getting pregnant.” (women from IDI participant)

On top of the challenges that happen in pregnancy situations; there is an awareness gap about the risk of pregnancy. Most female adolescent who lives on the street has poor awareness of the risk of pregnancy. A woman from IDI put her opinion as below.

“I think, the risk of pregnancy on the street is not high that much. Because we don’t have enough food and a comfortable lifestyle here. I don’t think I can be pregnant at any time I had sex. The reason I said this is, I had sex so many times on the street which is mostly is without my willingness. You can say I have sex almost every day. But I was pregnant only three times.” (women from IDI participant)

Another participant from FGD also supports this idea. She mentioned that the awareness among female adolescents on the risk of pregnancy with unsafe sexual intercourse is very poor.

“I think the risk of pregnancy on the street is high but Most female adolescents on the street do not have the awareness about the risk of pregnancy. They think that they cannot be pregnant at any time they had sexual intercourse, they think that if a woman is not in a comfortable lifestyle like she can’t get enough food, the risk of pregnancy is less likely. So mostly teenagers and youths who live on the street are very exposed to pregnancy” (FGD participant)

The finding indicates that unsafe abortion is highly practiced among women living on the street. As the respondent stated that female street women are more likely to experience early pregnancy due to rape and unprotected sexual intercourse while they are living and working on the street. As a result, the fate of this pregnancy is abortion which makes adolescents at high risk of getting health complications as most abortions are made in illegal and unsafe ways. Participants have a misconception that pregnancy can be aborted safely by taking some kind of drug (ampicillin) with coca-cola. One of the participants narrates her experience as follows.

“Before a month, I get pregnant again because some guy on the street raped me. And my friends told me to abort it. And when I think about it I was so worried about how to overcome the pregnancy and raising another child on the street…….Then some girl told me that about this medicine which will be taken with coca-cola to kill the baby inside my stomach. She told me it ‘is good and it will kill the baby so fast’. So she gave me the medicine and I bought coca-cola then I took it. After a day my stomach was so in pain and heavy blood was coming out of my vagina. then they took me to some traditional house around gende kore and the traditional women gave me some drink which was squeezed from leaves. But that drink does not give me relief, even if I take it all I was in pain and bleeding for two days….” (women from IDI)

The same story was narrated by another FGD participant as the following:

“….. 4 months ago, I get pregnant because of unwanted sexual intercourse. I was worried so much that how can I survive here with pregnancy and raising a child. My friend gave me some medicine to take with coca-cola and she told me that, this will kill my baby. Nothing was coming out of me even after a week. Then, we went to some women who do traditional leaves to abort the unwanted baby. I went there and she gave me some squeezed leave, I drink that and after a day I went through so much pain around my stomach and blood starts coming out of my vagina. I suffered a lot for 3 days. I smelled very bad. And the blood can’t be stopped finally I fainted. When I woke up I was in the hospital. It was an infection of abortion. Finally, they gave me medicine and I spent 4 nights there. That’s how I overcome my pregnancy story once. “ (women from FGD)

Almost all unwanted pregnancies ended up with abortion and most of the abortions are unsafe; in some sort of traditional way. The same story was narrated by another IDI participant.

“Almost every woman you see on the street has been pregnant at least once. They usually abort it. Adolescents and children are getting pregnant. Most of the girls here do not have the awareness of pregnancy risk or they are careless. I know 16 years old child who died after she got pregnant and tried something traditional inside her vagina. This is so sad. Even if we are living in the center of the urban at dire Dawa, these things are happening.” (women from IDI participant)

2. Sexual related problems

Street women and children don’t want to have a sexual relationship as they focus on fulfilling their basic needs like food and getting shelter. As the respondents reveal that No man on the street would desire to have a real sexual relationship with them and hence they end up being used. Besides, it was mentioned that teenagers are very exposed to unhealthy sexual relationships on the street because they are not aware of the reality out there.

“Sexual relationship on the street is not good. It is an extra need for us. We don’t have shelter here; we do not have proper food. So how can we think about sexual relationships with all those problems? But when I see some female children on the street, they are eager to have a boyfriend and start a sexual relationship. That’s not good because none of the street men want some girl on the street for a real relationship. They take advantage of us. But those female children do not have the awareness so that they simply go” (IDI participant)

A similar result was found from the focused group discussion that how much it is hard to live on the street without any protection and the only protection they secured is to engage in some sexual activity even if they do not want it.

“Do you think I will open my leg for any men I get here on my will? No, most of the sex here is forced and for money. For example, my first sexual act was rape. Most women on the street will have sex with street men to seek physical protection from any possible danger or attack while we live on the roads. We prefer the predictability of one man's violence to the unpredictability of street violence. They provide shield and protection in return we offer ourselves for sex in exchange” (Women from FGD)

This study found out that the other sexual-related problem for street children is STI, Gang rape and anal sex is reported among street women and children. Harsh and rough sex increases the risk of being infected with HIV AIDS and having an unwanted pregnancy. Female Street children are affected by STIs due to sexual abuse. It is clearly said that since they didn’t use a condom they are at high risk to be affected and the problem becomes worst because they didn’t get the appropriate treatment.

“I had STI problems more than 4 times on the street. There was a bad smell, an itching sensation and fluid coming out of my vagina. Before 1 week I was very sick of STI and I smell very bad, even my friends were not willing to sit beside me. I don’t even know where I catch the disease. And if you want to know everything, I have HIV in my blood. I confirmed that 5 years ago. (She cried badly). I don’t know where I got it. Most of the men do not want to use a condom when they had sex, even if I told them I had the virus.” (women from IDI)

Besides the high case of STI among women living on the street; It was also reported that there is a lack of awareness about STI among female children who live on the street.

“it is a very high and ugly thing. I used to have signs like vaginal discharge and a bad smell coming out from my vagina….And most of the children on the street have that experience but when we advise them to go to a health center, they refuse because they think that the smell is because they are unclean and they can't get enough water to get washed”(FGD participant)

It’s found that street girls practice commercial sex .they practice for money, food and other material. More child prostitution is the main source of income for the fellow family. As discussant reveal their street husband, elders and other street women enforce them to do sex for money; as a result, harsh and anal sex are highly practiced.

“There was a lady named ASHA who used to give me perfume and cosmetics to look good and make me work at night as a sex worker for drivers. I always inhale ‘Mastishe’ to forget and resist pain. …….I was forced by one guy to have anal sex. When I refused, he slapped me and knocked my head hard, I became unconscious, then all I remember was burning pain in my anus. He left me on the roadside. When I wake up, I was bleeding heavily. My friends took me to hospital and were hospitalized for 3 days.”(FGD participant)

Another participant also mentioned her story; anal and oral sex is highly practiced among female child who lives on the street

“I go out for sex in exchange for money (for living and food) but peoples are very rude. Heavy truck drivers and drunk men request us to do a very evil thing. They wanted to have sex by anus and oral sex. And most of them say that it is to prevent HIV and STD. they think that the disease is only transmitted by the vagina.” (IDI participant)

Most participants from IDI share a common idea which is; most of the street gangs or the men they had sex with think that STI/HIV can only be transmitted through vagina sexual intercourse. Thus; they are forced to do unsafe sexual intercourse. The quoted idea from the participant of the study is presented as follows:

“Sometimes I slept with men for money. even when I do business I get raped sometimes. Some guys asked me to get fucked in the anus, they request you to suck their dick. At that time when I say no, they will force me to do whatever they wanted. Most of the sexual act on the street does not involve the vagina. they do not want to fuck our vagina because we think the disease is caused only by vagina sex. So they forced us to do another evil thing.” (women from IDI)

The result obtained from the interview showed that homeless women are very exposed to gang rape, physical assault, and harsh sex.

“Yesterday two guys came while I was sleeping with my children then forced me to have sex, I refused so they beat me with stone and one guy stabbed me on my hand. Here is the place where he stabbed” in pain feeling and showing her fresh-dressed wound. “I also went to a police station, but I dropped the case because they asked me if I had a witness and evidence. I was assaulted around 5 o’clock at night so there were no pieces of evidence. (IDI participant)

Furthermore, this study found out being pregnant at an early age due to forced sex may lead victims to end up having permanent physical injuries. On top of this participants lost their virginity at an early age lead their psychological trauma. The other participant states her experience as follow

If you want me to tell you the day-to-day encounter ….trust me days won't be enough. Let me tell you one story, I joined street life with one of my friends when was 16 years old. One day, a random guy called me and offered to invite me to food. As I was hungry, I accepted. I have invited food in the beginning…..He then took me to a hotel and started showing me sex movies. He asked me the type of sex I would be willing to do and I replied “ I don’t want you to do anything. I just want to go out only.” He then had sex with me and took my virginity. He then called other 2 people to have sex with me afterward in the hotel. I was raped by a gang in Genaw hotel located in Gende Kore area. The 2 guys forced me into harsh sex……hmmmmmmm (crying) why you remember me those devils?.... one of them had sex by my anus and raped me. I was ill for quite some time…” (IDI participant)

The other striking finding from this study was about a sexual and reproductive health issue. Sexual and reproductive health service has an important role for a street female however, participants mention that there are barriers that hinder the street women from using the service. Among these participants mentioned that service providers have an unwelcoming face in providing SRH services. Street children are not treated the same way as the rest of the other patients. The treatments from some health professionals discourage and fear of stigma and discrimination hinder them from going back the second time.

“let me tell you one story, it is been 3 months since I delivered a baby girl at adiss ketema health center. at that time the doctor yelled at me ‘why would open your leg to have sex with everyone around with all your current problems?’ he shouted and treat like me a dog. Do you think I recklessly welcome everyone to have sex? No! life is tough. So even if I wanted to go health center for some kind of case, I won’t go there because they humiliate me. Even last time I had an itching sensation on my vagina but still, I haven’t checked. Yes I know I have to go to a health center whenever I face a sexual-related problem but I don’t feel good when I go there. “(IDI participant)

On top of this, the studies found out street women have a lack of knowledge about the availability of the service. As the participants stated that they have never heard about SRH service and the lack of information on available services is the biggest barrier and the lack of promoting their SRH services to street children make them not to use the service.

“As I told you, the sexual related problems like rape, harassment, unwanted pregnancy, HIV are very high among women living on the street. So I believe there is a lack of knowledge on what to do when they are pregnant and also where to report any sexual abuses. There is still so much work to be done. They do not know even what sexually transmitted disease is: especially the children. But they are suffering from the diseases. There is a lack of awareness about the place where to go where they face sexual-related problems. Also, there is negligence among the women living on the street due to different factors like substance abuse, rumors and like”(key informant)

This study provided a chance to explore the lived and living experience of women living on the street related to pregnancy and sexual-related problems. The finding reveals that women living on the street are highly exposed to sexual exploitation, rape, physical abuse, unwanted sexual relationships, unsafe sex, pregnancy and unsafe abortion.

Unwanted pregnancy is a regular and significant concern as indicated by the unique pregnancy events that occurred among women living on the street. Among the participant of this study, only 14 were currently pregnant during the interview and all of them have at least 2 pregnancy histories during their life on the street. Participants faced countless hardships and danger on the streets during pregnancy as it is accompanied by their homelessness, lack of food, clean water and adequate health care, although these are very essential for pregnant women. This finding is supported by other studies conducted among homeless women (5, 6).

The other striking finding of this study is sexual abuse during pregnancy among women living on the street. Street women are already the most vulnerable part of the community for sexual abuse on the street. These abuses continue while they are pregnant as well. The study participants mentioned that they are constantly under sexual predator potential attack whether they are pregnant or not. Our finding supports other qualitative research indicating sexual violence and physical abuse are part of their daily lives while in pregnancy. On top of the survival challenge of being pregnant on the street, they are impacted by physical, social discrimination, and mental wellbeing (1, 6).

In this study, Lack of awareness on pregnancy risk is the other reason for the incidence of unwanted pregnancy among women living on the street. They have a misconception that lack of enough food and poor economic status won’t expose them to unwanted pregnancy. In contrast, this finding is not supported by other studies conducted in USA and Ethiopia; the participants from those studies are aware of pregnancy risk. This discrepancy may be due to the difference in the study population and socio-demographic characteristics that they have a better awareness of the risk of pregnancy (1, 5).

As the pregnancy occurred among women living on the street is unwanted; the fate of this pregnancy is abortion which makes adolescents at high risk of getting health complications as most abortions are made in illegal and unsafe ways. It is reported that most of the pregnancy goes thru unsafe abortion such as self-induced abortion and using harmful traditional ways. The result of this study is comparable to different studies worldwide conducted among homeless women. In Kenya and USA study reported as seeking or attempting self-induced abortions and youth did perceive that there is a lack of accessible abortion services (2, 4, 7, 8).

The other sexual-related challenges which our study participants experienced were similar to the findings of previous studies. In our study homeless women experienced sexual assault, unsafe sex, STI/HIV; such experiences were also identified in previous studies (12). Our finding also conforms to similar studies conducted in Ethiopian cities. In previous studies, homeless women were found to be vulnerable to rape, physical abuse, STI/HIV and unsafe sex (3, 9, 10).

In this study, women living on the street did not get the most important sexual and reproductive health service for contraception, pregnancy, STI and safe abortion services. Homeless women suggested different reasons for not utilizing SRH services such as; lack of awareness, some health professionals’ discouragement, fear of stigma and discrimination. The findings of this study are consistent with the previous qualitative studies carried out elsewhere. It was also reported that encountering stereotyping service and disrespect by healthcare professionals (11, 12).

The finding of this study indicates that unwanted sexual relationships or survival sex is the most mentioned coping mechanism among women living on the street. Youth experiencing homelessness reported that they or someone they knew was involved with survival sex–engaging in sexual intercourse in exchange for food, money, or protection. Such experiences were also identified in previous studies. Driven by poverty and the desire for protection from street gangs and unwanted attacks, many women and girls find themselves using sex as a commodity in exchange for Protection, goods, services, money, accommodation, or other necessities. Such “transactional sex” involves sexual relationships, often with Street gang leaders. It reflects men’s superior economic, physical protection position on the street and access to resources. Women’s difficulties in meeting basic needs among the most dangerous living environment require them to form symbiotic relationships that offer protection for them (5, 13, and 14).

Women living on the street are more likely to experience physical abuse, sexual harassment, STI/HIV, unsafe sexual intercourse and unwanted pregnancy. As a result, the fate of this pregnancy is abortion which makes adolescents at high risk of getting health complications as most abortions are made in illegal and unsafe ways. This vulnerability makes them to use a different risky coping mechanisms such as unwanted sexual relationships/ survival sex and prostitution.

Lack of information on SRH service availability and approach from some health professionals, fear of stigma and discrimination hinder them from visiting health institutions. In addition, Lack of awareness on the risk of pregnancy and misconception on STI/HIV ways of transmission are more common in homeless women. The regional health bureau needs to understand the extent of the problem and plan to organize an awareness creation program on SRH services including a health education program about STI/ HIV transmission and risk of pregnancy should be provided. It is recommended that report and link homeless female adolescents with PAD organizations to build the financial capability of the homeless female adolescent, to find jobs that can sustain the livelihood of themselves and their children.

IDI ----- In-depth interview

FGD --- Focus group discussion

PAD --- Positive Action for Development

LSAA -- Labor and social affairs agency

Ethics approval and consent to participate

Ethical clearance was obtained from the institutional ethical review board of Dire Dawa University, College of Medicine and Health Sciences. An official letter of permission was sent to LSAA before data collection. Participants were informed about the purpose, benefit, risk, confidentiality of the information and the voluntary nature of participation in the study. Data were collected after informed written consent was obtained from each participant that their data will be included in publications. Confidentiality of the information given and privacy of the interviewee was highly secured throughout the data collection and the research process.

A consent form for those females who are under 18 years of age was obtained from the labor and social affairs agency of Dire Dawa city administration. Because of the under 18 adolsecents needs a parent/ guardine to make a decision on the informed consent. Since they are homeless and have no parent; Labor and social affairs agency is the agency who is responsible and working with homeless children as a guardine. Hence, the ethical clearance for those of under 18 children is given from labor and social affairs agency of Dire Dawa city administration after the ethics comitte of Dire Dawa University approved this procedure and official letter from Dire Dawa University is delivered to LSAA. The emancipated minors who are homeless with out any guardine are allowed to give informed consent under the LSAA.

Consent for publication

Availability of data and materials

All the data of this study are available from the corresponding author upon request.

Competing interests

The authors declare that they have no conflicts of interest.

Funding

This work has been funded by Dire Dawa University. But this organization did not involve in designing, analysis, critical review of its intellectual content, preparation of the manuscript and the budget funded by this organization did not include for publication.

Authors' contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising, or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted and agree to be accountable for all aspects of the work.

Acknowledgements

We are very grateful to Dire Dawa University for the financial support of this study. All study participants for their willingness in responding to our questionnaire.

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No competing interests reported.

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Pregnancy and Sexual Related Problems Among Women Living on the Street at Dire Dawa City, Ethiopia 2021

Status:

Version 1

Abstract

Background

Methods

Study setting and design

Study population and sampling procedure

Data collection tool and procedures

Data processing and analysis

Results

1. Pregnancy scenario

2. Sexual related problems

Discussion

Conclusion

Abbreviations

Declarations

Ethics approval and consent to participate

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