Our study indicates that FSW in South China are at high risk of unintended pregnancies and induced abortions. To our knowledge, this is the first study to investigate unintended pregnancy, and its associated factors among FSW in south China. Findings from this study could provide insights for the development of policies aimed at reducing unintended pregnancies, improving abortion care, as well as enhancing family planning programs targeted at FSW.
Unintended pregnancy due to commercial sex is prevalent among FSW in South China, with a similar rate observed in other low- and middle- countries such as Benin (16.4%)[17], Rwanda (26.3%)[18], and the Caribbean region (22.5%)[19]. This high rate can be attributed to the following reasons. Primarily, FSW often encountered financial burdens and difficulties in condom use negotiation[20, 21], leading to accepting more clients and engaging in more unprotected sex. Secondly, the majority of FSW are unstable and transient due to the criminalization of sex work in China[22], rendering it challenging for existing interventions to reach and assist them. Furthermore, family planning is not given the same priority in the current strategies for FSW health as it is in HIV/STIs prevention [23], resulting in a dearth of knowledge and utilization of relevant health services. Given the high prevalence of unintended pregnancies and the marginalized nature of FSW, exploring effective strategies to improve the knowledge and utilization of family planning service for them is needed. The Joint United Nations Programme on HIV/AIDS (UNAIDS) recommends prioritizing linkages between family planning and HIV/ STIs to help curb the HIV and pregnancy epidemic[24]. Several low- and middle-income countries have implemented this recommendation and it has been demonstrated to be cost-effective in reducing the prevalence of unintended pregnancy among FSW[25, 26]. Therefore, it is vital to integrate family planning service into current HIV/ STIs programs to mitigate the prevalence of unintended pregnancies for Chinese FSW.
Our findings indicate that the rate of FSW experienced pregnancy ended in abortion is remarkable high (96.7%), surpassing incidence rates in Benin (67.6%)[17] and Tete (35.9)[1]. The high rate of induced abortion may be attributed to the fear of losing clients and income, the violence from regular partners or family[5], the accusation of traditional social culture[27] and the legality of abortion compared to other countries[28]. A systematic review has revealed that abortion is the leading cause of mortality among FSW, as they often experience more health complications from abortion[7], especially with multiple abortion. In our present study, we found that nearly half of FSW reported having undergone more than one lifetime abortion. This discovery emphasizes the need to decrease the incidence of repeat abortion to shield them from the adverse effects of such procedures. The World Health Organization has advocated for the provision of abortion care for FSW[29]. Researches have demonstrated that offering post-abortion care to patients before their discharge from medical facilities can effectively reduce the recurrence of abortion[30, 31]. Moreover, many countries such as Zimbabwe[32] and Uganda[33], have recommended the expansion of knowledge and accessibility of post-abortion care for FSW. Nonetheless, less than half of females in China avail themselves of post-abortion care, and there is limited information about the utilization of such care among Chinese FSW. Hence, it is imperative for public healthcare institutions to establish and promote anonymous abortion services, ensuring that FSW can access safe and confidential services. Concurrently, healthcare facilities, alongside communities, should facilitate comprehensive post-abortion care and promote abortion education to FSW in China.
We found that few FSW (12.6%) have used modern non-barrier contraception. Despite the reliance on condoms as the primary form of pregnancy control for FSW, the risk of unintended pregnancies persists due to inconsistent condom use and condom failure[34]. Non-barrier contraceptive methods, especially long-acting reversible contraceptives, emerge as a dependable alternative, significantly reducing the likelihood of unintended pregnancies among FSW[35]. However, the uptake of non-barrier contraception among FSW in our study is lower than rates observed in similar populations in Cameroon[36] and Russia[37]. This discrepancy can be attributed to educational programs that predominantly promote condom use, neglecting to inform FSW about other modern non-barrier contraception[3]. Additionally, a considerable segment of unmarried or divorced FSWs fail to access complimentary contraceptive services, including long-acting reversible contraceptives, despite China's policy of providing non-barrier contraceptives at no cost to women. This policy is depended on marital status verification and is restricted to select venues, such as primary healthcare centers[22]. The necessity for additional intervention is underscored by these reasons, advocating for improved knowledge and access to non-barrier contraception for FSWs. More innovative and comprehensive strategies are being implemented in many countries to disseminate knowledge and broaden the availability of non-barrier contraception, incorporating peer-driven[38] and mobile-based[39] interventions. Moreover, WHO endorses dual protection as vital for preventing both unplanned pregnancies and HIV, reinforcing the need for dual protection—combining condoms with non-barrier contraception—to prevent both unintended pregnancies and reduce HIV/ STIs transmission[40]. Given the high burden of STIs and unintended pregnancies among FSW, it is essential to added modern non-barrier contraception and dual protection in current contraceptive promotion programs for HIV/ STIs prevention among Chinese FSW.
The present study has several limitations. First, data on unplanned pregnancies and abortion came from self-reports by FSW participating in the study, which can lead to information bias. Second, because we collected data on lifetime abortion, the study could not distinguish whether multiple abortion was the result of unplanned pregnancies due to commercial sex, limiting our ability to assess the direct association between unplanned pregnancies and multiple abortion. Third, even though we have a large sample size, the recruitment of FSW in this study was non-random and limited to cities with extensive experience of outreach services, potentially limiting the generalizability of the findings to other cities.