We want another job: A multi-country qualitative study on the self-reported health, social, and economic needs of female sex workers with children.

doi:10.21203/rs.3.rs-4814824/v1

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Research Article

We want another job: A multi-country qualitative study on the self-reported health, social, and economic needs of female sex workers with children.

https://doi.org/10.21203/rs.3.rs-4814824/v1

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Background

The mothering role of female sex workers, as the sole provider, in low- and middle-income countries (LMIC) is quite challenging and most of them turn into sex work to meet the basic needs of the family. Efforts to address their unique needs across the spectrum of matriarchy and often stigmatized occupational identity within the context of LMIC requires research-based evidence. The community-centric health and social care needs of 2657 female sex worker mothers (FSWM) in eight LMICs (Angola, Brazil, DRC, India, Indonesia, Kenya, Nigeria, and South Africa) were explored.

Methods

The data came from a community-participatory mixed method study conducted among 2657 women in 165 group discussions. The two-stage feminist ethics of care framework was applied to FSWM narratives to guide thematic analysis. In the first stage we focused on how sex work serves as means of survival and the second stage guided the duty to sacrifice for their children.

Results

Four major themes were identified using an inductive coding qualitative approach: assistance with alternative sources of income; healthcare needs; education needs for children; and equitable social respect/legal rights. Application of the feminist ethics of care framework, at the intersection of sex work and motherhood, revealed the leading priority for mothers in sex work is alternative sources of income. The findings reveled that engagement in sex work is for the survival of children and stigma and discrimination impede access to healthcare for female sex workers mothers and their children.

Conclusion

From a theoretical standpoint, our findings align with the two components of the feminist ethics of care; fulfilling self-care first and then making self-sacrifice in providing a nurturing environment for children. The most expressed need was support for alternative sources of income, to transition out of sex work, realizing the work-related threats and dangers for them and their children. This study suggests that legal and HIV protection may not be their highest priority. Local organizations should include the FSWM community as equal partners in addressing unmet health, social and economic needs to ensure that welfare program implementations are responsive to and prioritize the self-reported needs of FSWM.

Female Sex Worker mothers

Low and Middle Income Countries

Social determinants of Health

Feminist Ethics of Care Framework

Needs of Mothers and Children

The mothering role of female sex workers (FSW), surrounding the desire to provide a purpose and meaning to their children’s health and wellbeing [1], is similar in some respects to mothers in other occupations, albeit female sex worker who are mothers (FSWM) bear a social identity situated in their stigmatized occupational identity as sex workers. In many communities, this occupational identity undermines their respectable role in motherhood[2] and is tagged onto their children’s social identity as children of sex workers. There are evidence coming from non-LMIC context that sex workers reporting acute health needs that are not met due to structural and social barriers [3]. Nevertheless, their sacrifice of engaging in high-risk sexual behaviors, such as not using condoms in exchange for more money to meet the needs of their children, provides compelling evidence for their desire to provide for their children. [2]. A review of 21 studies, on FSW, conducted across 13 countries that included 9 low- and middle-income countries (LMIC), uncovered how FSWM negotiate between two conflicting identities, the identity of motherhood and marginalized occupational identity as FSW and emphasized the mother’s desire to leave sex work to become good role models for their children [4]. In many countries, single-parent FSWM are forced by law to relinquish their children to move them away from the dangers associated with their work environment [4]. Yet another study in Nairobi, Kenya identified motherhood as the reason for becoming resilient in the high-risk work environment [5]. A study conducted in the UK among FSWM explored the experiences of bonding with children following motherhood and viewed their body as a shared entity with their children[6] but the contextualization of bonding of FSWM in LMIC has yet to be examined.

Most FSW are single mothers, yet their maternal health and parenting needs are poorly recognized [7]. They are often victims of violence, police brutality, HIV infection, loss of social prestige [8, 9], and premature death [10]. Efforts to address the health-related needs of FSWM, including access to health care for mothers and children, have often been eclipsed by a narrow focus on sexually transmitted infection risk reduction and condom negotiations [11]. FSWMs’ revelations of their risky social and environmental circumstances provide a solid basis to formulate global health interventions and policies, not only to keep this population and their children safe from sexually transmitted, blood-borne and other infections but more broadly to achieve the United Nations’ 2030 sustainable development targets of reducing maternal deaths and saving the lives of children [12]. There is scant global knowledge on the comprehensive needs of FSWM and their children within the LMIC context, revealing specific socioeconomic, governance, and political structural challenges. Moreover, health needs and priorities change by the social, cultural, political, and healthcare structures of each country. Rather than exclusively emphasizing individual behavioral risk reduction, contemporary sex work interventions need to attend to the broader structural-environmental conditions that underpin vulnerabilities to HIV infection [13, 14]. In that vein, reducing financial vulnerability is noted as a key to overcoming structural barriers to accessing health and social services for FSW in India [15].

Current thinking of social determinants of health may require paradigm shift within the context of health, social and economic needs of FSWM and their children in LMICs. Structural determinants of health are a subclass of social determinants of health comprised of socioeconomic, governance, and political structures [16], that are beyond one’s control, whereas behavioral and some biological factors may be modifiable, if necessary resources are available and accessible. These structural determinants often push unemployed and sick women into sex work [16], further compromising their health and safety. Little is known about the health and social care-related mothering experience of sex workers in the LMIC context. A study conducted in the city of Kolkata, India, found FSW are capable mothers, capable of navigating effective positive changes through health communication to influence HIV prevention practices [17]. A study in Tanzania revealed the need to support children masked their enacting power and became the main driver to engage in HIV-related high-risk sex behavior of accepting more money for no condoms [2]. Even more, a significant interaction between the FSWM mothering role strains and depressive symptoms was identified in Mexico [1].

There is compelling LMIC country-specific evidence on socioeconomic circumstances and cultural influences that drive FSWM to sex work. Most mothers in India resort to commercial sex work afterbeing widowed or divorced and are thus considered cultural outcasts [18]. In addition, female sex work is considered a filial duty to support parents and siblings before marriage and the duty continues toward children and husbands, even continuing after marriage for some women [19]. In Kenya, some women enter sex work for money, after being abandoned by the abusive father of her children [20]. In Nigeria, sex work is highly stigmatized, however, some women are inclined toward sex work if they are widowed, divorced, or abandoned by their husbands due to being sterile [9]. In South Africa, prior to decriminalization, women reported selling sex during pregnancy and post-partum to support their children [21]. A study conducted in Canada among sex worker mothers reported barriers to equitable access to pregnancy and maternal health services due to low education, homelessness, and drug use,[22] and the situation in LMIC can be worse. It is unclear how these circumstances that push women into sex work can be improved through decriminalization alone.

There is a political debate about the decriminalization of sex work as a means of harm reduction. Post COVID literature almost exclusively focus on sex workers harm reduction of communicable diseases [23], as means to prevent transmission to public. FSWM in LMICs are subject many forms of harms including police brutality and societal discrimination. In 2019, when this study was conducted, each of the eight study countries had a different legal context for sex work but in most of these countries, sex work is legal. In Angola, sex work was only decriminalized in 2021, though the legal code indicates that taking advantage of the economic need for the practice is subject to punishment [24]. In 2002, the Brazilian government recognized sex work as a formal occupation and allowed entitlement to maternity pay, state-funded medical benefits, and pension [25]. In the DRC, female commercial sex work is legal and is a common way for unskilled poor women to earn money, wherein the majority of FSW are mothers with up to five children [26]. In India, exchanging money by selling sex in private is legal but commercially exploiting women or running brothels for profit is not legal. In Indonesia, the sex trade is legal in state-sanctioned brothel zones only. In Kenya, sex work is illegal, hence women face harassment by law enforcement [27]. In Nigeria, sex work is not only illegal, but FSW lacks legal protection from law enforcement, clients, and the public [28]. In South Africa, sex work has recently been decriminalized[29]. However, there is no research-based evidence from LMIC on the impact of decriminalization on the health and safety of FSWM.

This paper fills the gap in existing knowledge about the health-related needs of FSWM by critically analyzing the self-reported broad spectrum of needs of an extremely vulnerable and hard-to-reach population of FSWM in eight LMICs (Angola, Brazil, the Democratic Republic of the Congo (DRC), India, Indonesia, Kenya, Nigeria, and South Africa). In this paper, using data gathered as a part of a larger study (Willis et al., 2022), we examined the self-reported needs of FSWM in eight LMIC. The aim is to frame FSWM needs from the intersectional perspectives of motherhood and female sex work using an ecological framework, which includes multiple structural, societal and individual level determinants[30]. The framework promotes mental and physical health to advocate the protection of human rights and equitable access to health services and highlights upstream structural conditions and has been applied to the LMIC context [31]. Monitoring macro, system-level, and micro, individual-level health and determinants is crucial to tackling health inequities in vulnerable sub-populations in LMIC, especially due to a lack of data to guide programmatic efforts to reduce disparities [32].

While pinpointing the health and social care needs and priorities within and across countries situated in the four regions of the world, we make recommendations for need based public health enhancement program planning and implementation. The study findings can aid international and community-based organizations, health advocates, and minority health planners in developing and implementing effective country-specific programs to navigate healthcare access, social justice and to improve the determinants of health of FSWM and their children.

Our study data came from direct communication with FSWM giving voice to their experience. To increase the risky health behavior and safety of FSWM, it is important to use the local knowledge that exists within their communities [11] and community-based interventions have proven to reshape the mothering experience through identity recognition and providing social support for children [18]. A study conducted in Mozambique among FSW found sex workers have the potential to use the knowledge acquired through experience to save and protect their lives [33]. By mobilizing this knowledge, sex worker organizations and FSW-serving non-governmental organizations (NGOs) can adequately address FSWM’s unique needs and assist them in overcoming the structural challenges they experience through healthcare, family, legal, and support services to safeguard FSWM and their children [4].

Theoretical frameworks

The health priorities of FSWM in LMICs are influenced not only by the needs for individual survival but also by the needs of their children. This notion was used as the basis to apply the feminist ethics of care framework by McCloskey et al. (2021) [34]to explore mothering practices among FSW in India [34]. The framework originated from a psychological theory developed by Gilligan (1985) depicting how women negotiate choosing between individual survival and bearing the responsibilities of others, in this case, FSWMs’ own children [35]. We extend this notion to explore how self-sacrifice evolves when these mothers choose sex work [35].

Although our coding was inductive, allowing for themes, categories, and patterns to arise organically from the data, interpretation of the codes was guided by the two-stage feminist theory of moral reasoning applied to FSWM in India [34]. In the first stage of this theory, interpretations of needs are made with a focus on the self as “sex work serves as a means of survival”, whereas the second stage of needs-identification centers on a “duty to sacrifice for their children to achieve aspiration for them” [34]. The two stage-feminist theory, that applied to FSWM work in McCloskey et al. (2021), stemmed from the original work of women’s work of conception of self and morality, a two-stage process of individual survival and self-sacrifice for others in their care[35] (Gilligan, 1985). This theoretical foundation guided the interpretation of findings at the intersection of two identities: motherhood and sex work. Our analysis is the first to apply the framework to multiple cities across multiple LMICs.

Study Design

This data analysis came from an original mixed-method study that collected qualitative data regarding the self-reported needs of FSWM in the eight study countries. We obtained data via 165 group discussions in 2019, with 2567 women in total, in eight LMIC.

Though the research did not strictly follow community-based participatory research (CBPR) principles [36], the collaboration of community partnerships with local sex worker organizations and NGOs providing services to FSWs within each country was established by the lead researcher (BW) and followed throughout the entire research process. The local community partners: (a) reviewed and approved the data collection instrument; (b) identified geographic locations to ensure urban and rural sex worker communities were included; (c) assisted in identifying venues for data collection; (d) assisted in the recruitment of participants based on the pre-established screening criteria; and (e) assisted in collected data in some instances. Local community partner involvement in this study differs from the CBPR approach used in a sex worker needs assessment conducted in Canada [37], in that local partners in our study were not involved in data analysis for this paper. The lay summary of preliminary results was disseminated to each local partner through country and city reports. The CBPR is recognized as an appealing model for research with vulnerable communities [36].

Setting

The study countries were selected using five criteria: (1) high number of FSW; (2) high number of maternal deaths; (3) high HIV rates among FSW; (4) local partners willingness to participate; and (5) geographic regional representation covering four regions of the world, sub-Saharan Africa, south Asia, east Asia, and South America. Within each country the cities for data collection were determined by local partners based on the geographic location of the study population and included both urban and rural settings in each country. Once the cities were selected, the local partners determined the venue of data collection in each city.

Participants

These women were engaged in sex work from a variety of settings, including bars, brothels, parks, and fields. Country-specific percentages of FSWM who became pregnant during sex work ranged from 32–72%. The average pregnant FSWM, across eight countries, was engaged in sex work up to eight months of gestational age and returned to work on average one month after delivery. On average there were four children per FSWM with a range of two to five.

Procedures

Participants were recruited via purposive sampling by local partnering community organizations thatworked with FSWM. Local partners personally contacted known FSW in the locations where they work, including hot spots, brothels, parks, bars, and fields, and screened them for eligibility. The eligibility criteria included (1) females age ≥ 18 years; (2) mother to at least one child aged ≤ 10 years; (3) engaged in full-time sex work during the three-year period from 2016–2019; and (4) interactive with other FSWs in the community. Community partners did not report counts of non-responses or refusals for participation.

We collected data in a group setting, but all participants were given an opportunity to respond to each question. Individual responses were recorded but were not attached to a particular participant. Group discussions took place at venues that the local partners recommended and determined as convenient, safe, and confidential for the study participants. The study questionnaire, which included open and closed questions, was developed by the researchers and approved by the local community organizations. The lead researcher (BW) orally administered the survey in South Africa, Kenya, and Nigeria, while trained and supervised translators assisted in the administration of the questions in Brazil, Angola, Indonesia, India, and the DRC. All responses were recorded by the lead researcher in English with the assistance of the translators. Discussions following the open-ended question ‘What can NGOs do to help children of sex workers and their mothers in this community?’ formed the focus of this paper. During each group, the lead researchers recorded responses to this question and counted additional women who agreed with each response. For ethical reasons, no demographic or personally identifying data on participants were collected. Further details of the methodology are published elsewhere [10].

Data Analysis

We analyzed responses to the question ‘What can NGOs do to help children of sex workers and their mothers in this community?’ qualitatively for major themes, which we then quantified to rank the frequencies of each theme by country. Data were analyzed using inductive and axial coding [38]. We used an open coding approach to identify response themes and patterns, from which we determined a set of codes. General comments that did not specify a need were excluded. We then organized the codes into categories by type of need and assigned subcodes. Two of the authors (MF and SW) coded the responses individually, and then met together with the lead researcher (BW) to review and resolve any discrepancies. This iterative process continued until an appropriate coding consensus was reached (Kappa = 0.84, p-value < 0.0001 for the initial set of codes). The dominant categories were identified and interpreted as relevant to the overall aim of the study and then framed FSWM needs from the intersectional perspectives of motherhood and female sex work.

We tabulated the frequency of responses within each thematic category by country to aid partnering community organizations and international agencies in focusing efforts on country-specific health and healthcare needs. We selected salient quotes from study participants to include in the results, particularly any comments that emphasized or further illustrated the themes are presented in the findings. By doing so, we provide a platform for the participants’ voices via their direct narratives. Each thematic category finding was applied to the McCloskey et al. (2021) FSW mothering practices[34], derived from the original feminist ethics of care framework introduced by Gilligan (1977)[35] to illustrate multi-country intersectional perspectives of motherhood and female sex work.

Our study sample consists of mothers above the age of 18, on average having 2–5 children each, at least one under the age of 10. We included 799 responses in this analysis, that came from 655 participants in eight countries (Angola = 7, Brazil = 12 DRC = 140, India = 46, Indonesia = 12, Kenya = 264, Nigeria = 88, South Africa = 86).

From the responses, we generated 39 unique codes depicting the needs reported by participants. We then categorized these codes into five major categories depicted by country (Table 1): (1) alternative source of income; (2) healthcare for mothers; (3) education, safety and care for children; (4) healthcare and basic essentials for children; (5) social respect and legal rights. We included an ‘other’ category for responses that did not fit within the major categories and were not mentioned with large enough narratives to warrant detailed thematic categorization. The other category included needs such as ‘research’ and ‘saving circles’, etc. We counted multiple responses from the same participant falling into the same theme in Table 1 so that frequency of responses is greater than the number of participants.

Table 1: Country-specific categorization of FSW mothers’ needs*

Country	Needs
Country	Alternative source of income	Healthcare for mothers	Education, safety and care for children	Healthcare and essentials for children	Social respect and legal rights	Other
Angola	5 (35.7%)	4(28.6%)	3(21.4%)	2(14.3%)	0(0.0%)	0(0.0%)
Brazil	5(18.5%)	12(44.4%)	5(18.5%)	4(14.8%)	1(3.7%)	0(0.0%)
DRC	76(47.2%)	15(9.3%)	49(30.4%)	6(3.7%)	11(6.8%)	4(2.5%)
India	13(22.8%)	13(22.8%)	12(20.0%)	9(15.8%)	9(15.8%)	1(1.8%)
Indonesia	4(19.0%)	8(38.1%)	4(19.0%)	2(9.5%)	3(14.3%)	0(0.0%)
Kenya	72(23.4%)	58(18.8%)	65(24.4%)	40(13.0%)	56(18.2%)	7(2.3%)
Nigeria	40(38.5%)	13(12.5%)	25(24.1%)	17(16.3%)	3(2.9%)	6(5.8%)
South Africa	19(17.8%)	16(15.0%)	37(34.5%)	19(17.8%)	9(8.4%)	7(6.5%)
Total	234 (29.3%)	139 (17.4%)	210 (26.3%)	99 (12.4%)	92 (11.5%)	25 (3.1%)
* Includes multiple responses from the same participant.

The themes and categories that stemmed from the data in eight LMIC are listed in Table 2 alongside the feminist ethics of care components.

Table 2: FSWM needs alignment with the feminist ethics of care perspective *

Feminist ethics of care components

Needs of Female Sex Worker Mothers Theme

Decision-making focused on self: Individual survival and care for self.

Caring for others: Maternal duty to provide for children.

Principles of non-violence: safety and rights of self and children

An alternative source of income to stop or supplement sex work; Affordable and accessible healthcare for mothers.

Education and safety for children; Healthcare and essentials for children.

Social respect and legal rights for sex worker mothers and children.

*The theoretical framework was originated by Gilligan (1977) [35]and applied by McClosky (2021) [34]for female sex worker mothers in Mumbai, India.

Individual survival and care for self

The two categories stemming from the FSWM data were illustrated within the individual survival and care theme (Table 3) including the need for alternative sources of income to stop or supplement sex work and affordable and accessible healthcare for FSWM.

Table 3: Coding summary of needs of FSWM relating to alternative work and healthcare.

Need Category	Code: Contents
Alternative sources of income	Business capital: Capital/Microfinance loans to start income-generating business/savings programs, family and social support.
	Business training and education: Training for business (sewing, handicrafts, financial empowerment, etc); Education/job skills (childcare, social work, hospital work, hairdressing, catering, fashion, caregivers).
	Business supplies: Supplies (sewing machine, items to sell).
Affordable and accessible healthcare	Health education: Safe abortion, postnatal care, safe sex, and nutrition education during pregnancy.
	Healthcare: Prenatal, postnatal, and post-abortion clinical care.
	Abortion care: Access to safe abortion and education.
	Psychosocial care: Support groups, mental health, counseling, suicide prevention.
	Shelter: Shelter during pregnancy.
	Contraceptive: Condom distribution and family planning needs.
	Medical care: Mobile clinics, checkups, STI testing, health card.

Alternative sources of income to stop or supplement sex work

The most expressed need was support for alternative sources of income, including assistance with capital/financing, skill training, and education, as well as supplies to start small businesses (Table 3). This was the most frequently reported need in Angola, DRC, India, Kenya, and Nigeria (Table 1). For some participating women, the desire to find alternative sources of income was driven by a wish to avoid the health risks associated with sex work and to support the family. For example, in the DRC, FSWM expressed a desire to quit sex work and to live a healthy life; they viewed sex work as a dangerous occupation that exposed them to HIV and violence perpetrated by their clients. Four FSWM from Bukuva, DRC summed this up as follows.

We want another job; this does not make enough money. We don’t want this life. We want to be healthy. We are exposed to too many dangers. (Participants from Bukuva, DRC)

In another city, Kinshasa, DRC, FSWM expressed their desire to learn skills and they directly linked this need to motherhood. One mother from DRC expressed taking care of her children as a motivation to change her work of “selling her body” for another source of income. FSWM in Abuja, Nigeria, related the desire to do another “business” to minimize the danger of becoming infected with HIV and perceived this as a way of stopping the transmission of the virus.

We don't want this job; we want a center to learn skills or new business because we are tired of this work. We want to do another business so we can take care of our kids. So we do not have to sell our bodies. (Participants from Kinshasa in DRC)

Most sex workers don't want to do [sex work], they want to do [other] business, but don't have money and now have HIV. So [we] need help to put a stop to it. We talk more about HIV, but people forget that sex workers are mothers too. (Participants, Abuja, Nigeria)

The FSWMs’ desire to quit sex work in Mombasa, Kenya is similar to the FSWM in DRC and Nigeria and they further reiterated their motherhood role of wanting to spend more time with children.

The notion of seeking economic empowerment through other avenues was described as a way to escape sex work and to expand their workforce opportunities. Economic empowerment as they suggested can be gained through more education, vocational skills training, and small startup funds, like microcredit or materials. Participants also spoke at length of existing challenges to finding alternative employment and sources of income, including the lack of sufficient capital to start a small business.

We need income-generating projects - we do sex work full-time, and so we have little time to spend with our kids. With other work, we would have more time to spend with our kids. (Participants, Mombasa, Kenya).

[There is a] need to empower sex workers so that they can do something else.

(Participants, Abuja, Nigeria)

Offer micro-credit or offer professional training to generate employment. (Participants, Luanda, Angola)

In India, FSWM reported pursuing alternative work but elaborated on their experience facing societal and familial barriers and lack of support. They insisted these barriers must be removed for those who want to leave the sex work.

[We need to] get some [other] work and protection. Though I tried to go for some good work, my family members don’t help me. It is better for me to hang and die. (Participants, Salem, India)

Mothers in Chennai, India expressed the need to “Remove barriers within society so that [sex worker] mothers can make the change.”

In summary, FSWM caring for self-notion is centered around leaving the dangerous occupation of sex work for alternative businesses and this notion is consistent across eight countries. The reasons for wanting to leave sex work were situated within the intersection of motherhood and sex work but took different forms across countries and cities, including preventing HIV contraction, dangers associated with sex work, and needing more time for child-rearing.

Affordable and accessible maternal care and preventive healthcare

Health needs were the second most frequently reported need overall and the most reported need in Brazil, India, and Indonesia (Table 1). This theme covered maternal, sexual and reproductive health needs and the need for mental health support (Table 3). Some women, from Nairobi, Kenya, want income support during pregnancy and after childbirth. Participants in Kenya and South Africa suggested ways to provide mental health care to themselves and their children, and in India, suicide prevention was highlighted. Overall, one of the most pressing prevention needs cited was psychosocial support for mental health and suicide prevention.

[We need a] support group for pregnant moms for those who want to commit suicide or abandon their children.’ ‘ [We need] counseling for moms and children.’ (Participants, Mombasa, Kenya)

Prevent suicide. A week before, I tried suicide by using chemical powder; I got rescued by my neighbor by giving [me] soap water. (Participants, Warangal, India)

[We need a] place to care for the pregnant sex workers and to get counseling and to debrief because they are stressed. (Participants, Durban, South Africa)

Women expressed the need for a range of maternal health services including education on and access to safe abortion and postnatal care, the need for financial support during pregnancy and childbirth as well as during the perinatal, and post-abortion periods, and access to shelter during pregnancy. The need for shelter specifically during pregnancy and the post-natal period is important as many sex workers live in or near the brothels, on the street, or other venues where they conduct their work. Some participating women felt that these spaces were neither suitable nor safe for them, especially during pre- and post-natal periods. In Indonesia, contraception availability, and protection against unwanted pregnancy were also highlighted.

[We need support on] how to prevent pregnancy because management won't allow pregnant sex workers to work, we need help for pregnant sex workers. (Participants, Jakarta, Indonesia)

Give a sex worker a place to stay when they are 7–8 months pregnant and then to rest one month after giving birth. (Participants, Johannesburg, South Africa)

We want NGO to educate us on safe abortion [because]we are dying from the use of traditional medicine. (Participants, Abuja, Nigeria)

Furthermore, FSWM emphasized the need for sexual and reproductive care education. As one woman in Mombasa Kenya stated, “Sensitize sex workers about safe abortion andSTI.”.

Women in Kenya and DRC expressed the need for financial support to buy food during pregnancy because they cannot work.

We need financial support to buy food because when [we are] pregnant, you can’t work and become frustrated and want to commit suicide. (Participants, Mombasa, -Kenya)

Requests were also made by participants for cervical cancer treatment in Mombasa, Kenya. Besides the frequently reported need for affordable and accessible maternal healthcare, FSWM participants in Bukuva, DRC, Abuja, Nigeria and Jakarta, Indonesia, expressed the need for advice, education, and support on sexually transmitted infection (STI) prevention and treatment. In all study countries, FSWM participants discussed the need for STI prevention, including frequent testing for syphilis and HIV, and access to and instruction on how to use condoms. This need for condoms was shared by FSWM in Abuja, Nigeria, and Rio de Janeiro, Brazil since the condom distribution programs, that were previously made available, in these cities were no longer available to FSW. In addition to condoms, which they found hard to negotiate with clients, FSWM in Kinshasa, DRC, expressed the need for birth control pills and family planning injections. The idea of HIV/STI prevention came up frequently, in reference to reproductive cancers.

We need health talks about preventive care. Provide preventive care with frequency. [We] need blood pressure tests, PAP tests, HIV and mammography testing. (Participants, Rio de Janeiro, Brazil).

Participants cited multiple barriers to accessing health services including stigma and discrimination experienced in the hospital. The participating women posed solutions to improve affordability and to overcome barriers to accessibility such as having health facilities supported by community-based sex worker organizations, and advocacy work towards eliminating stigma held by health care workers as suggested by FSWM in Mombasa and Nairobi, Kenya. The Lagos, Nigeria, participants proposed training older sex workers about safe abortion and other aspects of maternal health as a potential solution to avoid discrimination in hospitals.

We need medicine in the clinic…we do not want to go to the hospital because we experience discrimination and stigma. (Participants, Kinshasa, DRC)

Support health facilities where community-based organizations can help sex workers. Sensitize health workers, teachers, and the police. Ten percent of sex workers are arrested [and] if arrested, there’s no one to care for their children so they go to the street and beg. (Participants, Mombasa, Kenya)

In summary, the second important “caring for self” notion was centered around support for FSWM mental and physical health with a special focus on pre- and post-natal care. The FSWM orientation of caring for self covers comprehensive psychological and physical health needs that include a continuum of care starting from prevention of stress leading to suicide, unwanted pregnancies, and STI, through pre and post, abortion and maternal care. Their recommendations included making the care available, accessible, and affordable.

Maternal duty to provide for children

The two categories that emerged under this theme are wanting to have education, safety, and care for children (Table 4), as well as healthcare and basic essentials for children. The subcategories and codes under this theme are summarized in Table 4. The FSWM prioritized caring for children as the next pressing need for them and depicts their mothering of care responsibility to provide the care and protection of their children. Providing a formal education for children was seen as rerouting them from being exposed to sex work, preventing them from becoming sex workers, and once employed rescuing mothers from the risky sex work.

Table 4. Coding summary of FSWM needs of education, safety, and care for children

Category	Codes: contents
Education for children	School: Uniforms, books, fees
	Scholarships: Fees and boarding
	Skills training: Youth training school
	Sex education: Education for daughters: sex education and HIV prevention
Safety and care (medical and healthcare) for children	Training on child infant care: Train other sex workers for childcare
	Psychosocial care: Mental health, recreation, social support
	Medical care: Immunization, STI prevention Health care: Safe hospital for children
	Care for abandoned/orphaned children: Orphanage
	Childcare: Creche, night care, shelter, care for protection, caregiver for children
	Trust fund: Trust fund for children
Basic essentials for children	Care for malnourishment
	Clothing: Female undergarments, shoes and clothes for children
	Food: Food parcels, Food serving program for moms and kids, Milk for infants and breastfeeding mothers
	Housing: Housing, A safe home for mom and kids, shelter to protect from bad weather,
	Financial aid: Financial support during pregnancy.
	Other needs: Toiletries and diapers

The three sub-categories that fall under this theme are described below.

Education for FSWM children

FSWM in the four countries in the African region frequently reported needs related to their children’s education such as school supplies, scholarships, sex education, and safe childcare (Table 4). Additional needs for essentials, such as food, clothing, rent, financial support, and housing were also mentioned. Lack of money for supplies and clothing was cited as a major reason for children missing school, in study African countries. Education was described as a way of getting children off the street and preventing them from entering sex work themselves, and eventually, as a means for the mother to eventually leave sex work. Relatedly, the participating women emphasized the need to sensitize teachers to avoid discrimination in schools.

Most sex workers can't afford school fees, we need 3,000 KSH per term for primary and 30,000 KSH per term for secondary [We need] help to sponsor teenage children to go to boarding school so they don't see what [their] moms are doing. (Participants, Kisumu, Kenya)

Help children get a good education so they don't become like their mothers. (Participants, Mombasa, Kenya)

We need children to get educated and work and rescue their mothers. (Participants, Johannesburg, South Africa)

Our children are on the street because when I work, I am on the street, and I can’t help them with their education. (Participants, Kinshasa, DRC)

Safety, medical and health care for FSWM children

The need expressed by participants for raising children away from FSWM workplaces (childcare centers and even orphanages Table 4) was primarily for children’s psychological safety and also as a precautionary measure to prevent them from being exposed to sex work to gain respect for motherhood and turn the daughters away from becoming sex workers. A participant from Salem, India, added a psychosocial reason for the need to raise children away from her workplace. Others specifically cited the risk of daughters becoming sexually exploited.

(We) need a shelter for the children where they are safe. A place away from where the mother works but can visit them. The caregiver must be another sex worker. Children hear what people are saying in the brothel. (Participants, Johannesburg, South Africa)

[Children should be raised away from sex work], to gain [their] trust. - After knowing that their mother does sex work, confidence is lacking in the family and the children don't trust their mother. (Participants, Salem, India)

Girls need to be raised away from their moms. They need a hostel. Otherwise, they will follow mom into sex work. (Participants, Bukuva, DRC).

Children don't have a hospital to go to. We are dying because there is no one to care for them. Participants, Lagos, Nigeria

The only thing we want is for our kids to get treatment in the hospital. We get treatment in the clinic, but our kids don't get care here. (Participants, Kinshasa, DRC)

Basic essentials for children

Participating FSWM also expressed the need for medical and psychosocial support for their children. Many FSWM were concerned with protecting their children from HIV. In Durban, South Africa, and Kisumu, Kenya, FSWM specifically emphasized the need for PREP (pre-exposure prophylaxis for HIV) for teenagers as well as the provision of sex education. Malnutrition was another major concern for FSWM. Participants in Kisumu, Kenya, explained that when the children are left alone and hungry, they go to the street looking for food where they encounter other risks. Similarly, in Johannesburg, South Africa, participants cited the need for food and basic needs.

[We] need the sex workers with kids to get milk and food, because some kids die. Many children of sex workers are malnourished; some kids don't eat for the whole day. ( Participants, Lagos, Nigeria)

[We] need a center to protect kids from kiwashiorkor. The center that treats kwashiorkor no longer exists. (Participants, Bukuva, DRC)

In summary, FSWM expressed their duty to their children - to give them a good education, health care, and nourishment so that they will not become sexually exploited. FSWM view education for their children as a mode of avoiding and escaping the dangers of sex work for themselves and their children. This is framed in moral ethics of care framework as moving towards the stage of self-sacrifice for the care of one’s children. Besides providing education for children, by sending them to school, children will have a safe place away from where their mothers conduct sex; this is a way to gain ecological safety.

Safety and rights for self and children

The need for rights and respect for FSWM and their children was one of the prominent needs expressed by participants in Kenya. Social respect and legal rights were mainly for mothers but the need for destigmatization and prevention of discrimination for children was mentioned around school environments (Table 5).

Table 5: Social respect and legal rights for FSWM and children

Category Code: Contents
Social respect for and legal rights of FSW mothers	Non-discrimination: By healthcare workers, police, children in schools, equity in access to care
	Physical safety: From other sex workers, clients
	Legal rights: Police, legal care
	Recognition: As mothers
Respect for children	De-stigmatization: Of schoolteachers and students
	Discrimination: Healthcare workers discriminate against the children of sex workers
	Sensitization: Of schoolteachers

Social respect and legal rights for sex worker mothers and children

Overall, social respect and legal rights needs were the least reported elsewhere but highest reported in Kenya. Legal rights for sex workers include preventing stigma and discrimination by society in general and specifically by healthcare workers, police, and school staff. Our study participants revealed experiencing a lack of respect and threats to their safety from clients who make videos and take pictures of them while working to distribute on porn social media sites. Further in Mombasa, Kenya, women cited examples where the clients of FSW raped them if they did not have money to pay. This was framed as “lack of security from clients” by participants in Bukuva, DRC.

Participants in Mombasa, Kenya suggested “educating the community to stop discrimination and stigmatization of sex workers and their children.”

The need to sensitize the community regarding sex work was expressed by the participants in the cities of Nairobi and Mombasa in Kenya. The participants viewed this within the context of a lack of “sex worker rights”. Along the same vein, in Mombasa, Kenya, participating FSWM scorned media portrayal of FSW as creating negative impressions; one woman suggested “Get media to report sex worker issues fairly.” In, Jakarta, Indonesia, FSWM participants attested to a lack of moral support by society due to “social stigma” and indicated that “this kind of work has negative feelings by the society”. In Chennai, India participants wants help to “secure their lives as well as to raise awareness of the dangers (of FSWM’s experience).”

A lack of legal protection and rights by law enforcement emerged in each study country. Participants described several undesirable situations that occur when they get arrested by the police. In Nairobi, Kenya the participants also cited leaving their infant children neglected, when whose mothers are arrested.

Some [of us] work at night and we get arrested. [Then] the social worker takes the baby away. (Participants, Durban, South Africa)

When the mom is arrested, police do not bring the baby to prison [to breastfeed]. (Participants, Kisumu, Kenya.)

If [a FSW is] arrested, [she] leaves the baby starving for three days. Sometimes the neighbor brings the baby to the court to suckle. (Participants, Nairobi, Kenya)

The two identities, sex worker and mother, conflict in many societies, wherein motherhood is being portrayed as respectful and caring, on the other hand, sex work is often stigmatized as shameful, immoral, and/or indecent. The participants insisted on needing greater legal support. Many participants described undesirable situations they face, when they seek support from the police, when they’ve experienced violence from a client, but at present, the police do nothing to help. Other participants described the police as clients who perpetrate violence against them. As participants from Kinshasa, DRC, said “When the police sleep with us they beat us.”

Societal respect for children

Participants reported the stigma suffered by their children resulting from their mothers being sex workers. Participants emphasized the need to sensitize healthcare workers who discriminate against sex workers and their children.

Some women cited a lack of education among FSWM children about their rights and the need to train them as well as the need for legal support to avoid child labor exploitation.

We need protection from the police, who rape us. (Kinshasa, DRC)

We need a [legal] office to report cases where our children are beaten or raped because the police do not help sex workers. (Participants, Nairobi, Kenya)

We need lawyers to help sex workers when [they are] assaulted. (Participants, Nairobi, Kenya)

Sensitize sex worker sons on their rights through education. (Participants, Mombasa, Kenya)

[We need] legal support to address when people exploit our children for labor. (Participants, Kisumu, Kenya).

In summary, participating FSWM expressed the need for respect from the society including the enforcement sector, education and healthcare institutions and clients and expressed the need to reinforce their legal rights as mothers and workers. Participants emphasized children should also be respected and their rights should be restored. FSWM participants’ expression of needs under this category illustrated their desire to maintain safety for themselves and their children in society, as well as a desire to sustain equal rights to participate in society. This notion differs from the traditional feminist ethics of care perspective of portraying non-violence against self.

This study is the first global study that explored female sex workers' needs within the intersection of motherhood and sex work in eight LMIC, covering four regions of the world. This is the second study on FSWM whose findings were interpreted within an ethics of care framework for women, designed and interpreted within an LMIC context [35]. Findings that came from eight LMICs in this study were mostly aligned with the first study that applied the same theory to FSWM in one city in India. Similar to the Indian FSWM study we also found not only participants choosing sex work for individual survival and care for themselves and but also to fulfill a maternal duty to provide for children. Even further, similar to the Indian single city study, we found FSWM in eight LMIC continuing sex work for the benefit of providing financial support to children and found no evidence of FSWM discontinuing their sacrifice towards children. In contrast to the single city, India study, ours is the first global study that disclosed no justification of sex work by mothers in sex work, instead expressing the need for another job, emphasizing the need to transition out of sex work. None of the participants in any study country, including India, justified sex work. However, in that Indian study, FSWM who justified sex work came from Mumbai, India and our Indian study participants were from five other cities, Hyderabad, Nasik, Salem, Warangal, and Chennai. Rather, our study participants insisted on support to seek alternative sources of income as a conscious mode to leave sex work and help their children become educated, healthy individuals. The FSWM participated in the same country of India has different demographic characteristics and most FSWM in the Mumbai study were unable to read and write and were trafficked into sex work. These factors may have contributed to the differences. Further research is needed to confirm these within country-city level differences.

The last level of feminist ethics of care was framed by women exercising non-violence by deciding not to abort their child [35]. Our findings uncovered FSWM participants' suggesting the need for violence prevention strategies to protect them and their children from societal injustice, as well as pre- and post-maternal and abortion care, adding new dimensions to feminist ethics of care within the context of FSWM. Therefore, the principle of non-violence applies in the form of ecological security, merely FSWM falling victims of social environments as Lorway (2018) uncovered in their study among, FSW, in Nairobi. Kenya [11]. In our study, lack of ecological safety for FSWM and their children was reported in the healthcare, education, and legal service sectors and this was not elicited in the Mumbai, India study. Societal discrimination of FSW is not limited to LMIC. A study conducted in China, among older FSW, framed societal discrimination because of ‘occupational stigma’ and suggested strengthening social networking and support from ‘gatekeeper’ organizations [39]. There is ample evidence coming from the literature that stigma and discrimination impede access to healthcare and negatively affect mental health [40]. Protection of FSWs from the law enforcement sector is rarely addressed in the literature. The local ecologies of security viewpoint Lorway et al. (2018) suggested has been noted as a means of providing safety from violence and economic exploitation to this population [11]. A study conducted among female sex workers in Surabaya, Indonesia framed structural violence and brutality they experienced as a consequence of the societal tendency to denial of their rights due to the conception of FSW as “immoral women” [19]. Our study findings provided ample evidence against this societal conception and depicted FSWM's desire and commitment to their children’s well-being. It is important to do more in depth investigations on how the decriminalization of sex work protects FSWs and their children to gain ecological security and safety.

A global perspective of the healthcare needs, and social and political structural issues of FSWM is lacking in the literature: most studies focus narrowly on the social determinants of HIV [41]. Our findings suggest the need for an alternative source of income, the most pressing need to leave sex work is not confined to a single country or a region of the world but is universally true across four regions and all eight study countries. The need and desire to leave sex work that we uncovered are not only driven by individual survival and caring for self, as Gilligan’s first stage of ethics of care argues, but to spend more time with children, raise children in a safe environment, and become a good role model for them. Most mothers in sex work in LMIC, enter sex work out of necessity, seeing it as the only way to support themselves and their children. [20, 42]. Some studies in LMIC, including three study countries, Kenya, India and South Africa, reported that women can achieve financial independence through sex work but others, as in the present eight LMIC study, have documented that the sex work is financially inadequate or only adequate when additional risks are taken [20, 42–44]. For example, in Swaziland, FSW reported having sex without condoms for higher compensation to provide food or transportation for their children [45]. The desire to leave sex work for other employment has been reported by FSW in Kenya and India, but most women lack the support needed to take this step[20, 46, 47] (Mastin et al., 2016; Nyariki et al., 2022; Sinha & Prasad, 2021). A study from Kenya conducted during the pandemic reported reduced income and higher levels of food insecurity among FSW [48], and so it follows that the pandemic and subsequent inflation and food insecurity could push more mothers into sex work and exacerbate existing needs uncovered in our study. A study conducted in a developed country Canada, introduced a nine-month sex work exiting program that includes, assistance with housing and income generating activities and the program success outcomes are yet to be evaluated[49]. There is a need to implement transition out of sex work for FSWM within the context of LMIC.

Our study participants cited the need for employment alternatives to sex work as well as education for children across eight countries; this finding was similar to the perceived needs of FSW, identified by another study in Nairobi, Kenya, through a different NGO[46] affirming the validity of our study’s findings. Our study participants across eight LMIC insisted on having macroeconomic policies and programs to empower them with the necessary skills and monetary aids to leave sex work for an alternative source of income while also removing social, cultural, and institutional barriers to achieving success in the job market. From the feminist ethics of care perspective, we argue sex work is a means for survival for mothers; they sacrifice themselves, putting themselves at risk of contracting HIV, experiencing violence, and suffering trauma, because they have no other means to survive and ensure the survival of their children. None of these women preferred sex work as a means of survival if other alternative work was available. There is a considerable gap in research-based evidence on transition to and from sex work by mothers within LMIC.

The need for pre-and postnatal care and post-abortion care that we identified is generally overlooked by donors and governments that prioritize HIV and STI testing and treatment [7]. Perhaps one of the most pressing prevention related needs cited in our study was psychosocial support for mental health and suicide prevention. For context, in the larger study from which this sub-analysis was derived, suicide accounted for 13.6% of the 2,112 FSW deaths reported to have occurred between 2014 and 2019 across eight countries [10]. Proposed harm reduction strategies to safe guard sex workers lives that have been recommended [50] should include psychosocial support during pregnancy and at the post-abortion stages.

The requests for childcare and educational support in our study show that FSWM desire a safer environment and a better future for their children. These findings align with the literature; for example, FSWM in Cameroon have reported that educating their children would prevent them from entering sex work and facilitate better ways of living [42]. Similar to our study participants, childcare challenges have been raised among FSWM in Kenya and India where some women report having to take their children to work or leaving them alone at night[20, 51] (du Plessis et al., 2020; Nyariki et al., 2022). FSWM in our study reported the need to gain respect from their children and portray them as good role models and suggested achieving this by raising children in another environment and not exposing them to sex work.

Stigma and discrimination within healthcare facilities spanned across regions, countries and cities in our multi-country study. For FSWM in Kenya, the most frequently expressed need was for social respect and legal rights; this was more commonly expressed in Kenya than in any other country. This finding is unsurprising given that in Kenya, police discrimination, misconduct, and stigmatization experienced by FSW have been well-documented area of violations of human rights laws [52]. Even further, a scoping review on FSWM that covered 29 studies, including LMIC that we studied, revealed stigma and lack of legal protection undermine FSWM’s mothering role in seeking good education and healthcare for children [4]. Further research is needed to explore decriminalization of sex work and influence on social respect and legal rights of FSWM in LMICs.

From a theoretical standpoint, our findings align with the two components of the feminist ethics of care theory[35]Gilligan, 1985). Firstly, FSWM priorities are given to fulfilling self-care, meaning caring for one’s own health, to prevent unwanted pregnancies, poor mental health, and sexually transmitted diseases. Secondly, our findings justified self-sacrifice in making a nurturing environment for children. These priorities were expressed directly and through their requests for more enabling healthcare environments, like non-stigmatizing and non-discriminatory facilities and workers, to reduce sex work-related health risks. In contrast to McCloskey et al., (2021)[34] we did not find FSWM focused on self-health and well-being from the perspective of escaping exploitative and unfulfilling family relationships, instead, our participants were dedicated to fulfilling their motherhood responsibilities. This duty of care for children overrode the transition of Gilligan’s feminist ethics of care – discontinuation of ‘sacrificing their needs at the expense of others’[35] when contextualized within FSWM. Summing up the contents in the themes, FSW mothers continued to sacrifice for the care of their children. This finding that emerged across eight LMIC is partly incongruent with the finding of FSWMs in a single city of Mumbai, India [34].

Limitations and Strengths

One limitation of the study is that we asked each question to each group and recorded all responses offered, rather than asking the question from each individual participant, which would have provided each participant an opportunity to elaborate on responses. Other limitations include potential response bias from participants, a risk in any qualitative data collection, where the participants may have responded in a way deemed favorable to the interviewer. As the discussion groups were conducted by a single author, the lead researcher, interobserver bias is also a potential limitation. Besides these limitations, our findings are congruent with studies conducted among FSWM in single-city LMIC country studies. We suggest city and country-based policies need to be developed to protect FSWM and their children from being exploited and to restore their rights.

Based on the findings in this study there is an urgent need to develop and implement strategies and programs that make viable alternate sources of income accessible to FSW enabling transition out of sex work. Educating their children would enable them transition out of sex work and facilitate better ways of living for the entire family. The main upstream determinant of health revealed by our findings was financial (in)security: there is a clear need to develop and implement strategies and programs that increase the availability and accessibility of viable alternate sources of income for FSW, especially those who are or will become, mothers. In our study, lack of ecological safety for FSWM and their children was reported in the healthcare, education, and legal service sectors. Our study participants suggested sensitizing sex workers’ mothering role among healthcare and education service providers, by strengthening the laws to protect against discrimination of FSWM and their children. While decriminalization of sex work is critical, this study findings suggest that legal protection may not be their highest priority. Local organizations should include the FSW community as equal partners in addressing unmet social, economic and health-related needs to ensure that interventions are responsive to and prioritize the self-reported needs of FSW.

Ethics approval and consent to participate

The study protocol, consent forms, and questionnaire were reviewed and approved by the Institutional Ethics Review Board of Portland State University, USA (Protocol #184888). The standard under which this study was conducted is the US Department of Health and Human Services (HHS) standard for Protection of Human Subjects (US Code, Part 46, Protection of Human Subjects), referred to as the "common code." Additionally, each local partner approved the use of the data collection questionnaire and study forms after having the opportunity to review them and ensure they met local ethical standards and participant protection requirements. All participants provided informed consent to participate either by signing the consent form or putting an x in the consent form, if illiterate in English.

Funding

This study was supported by New Venture Fund [NGDF-GLO35-NVF-007627-2018-09-03]. The time of BW for the paper was supported in part by a grant from the Bill and Melinda Gates Foundation & Melinda Gates Foundation [INV049925]. Funders played no role in study design, data collection, analysis or reporting.

Author Contribution

S.D.S.W: Contributed to the conceptualization, data management, analysis, interpretation of results and writing the manuscript,M.F.: Contributed to the conceptualization, data management, analysis, interpretation of results and writing the manuscript,W.L.M.: Reviewed the manuscript and contributed to editing,E.P.: Coordinated data entry and cleaning,B.W.: Secured funding, designed the study, trained and supervised local staff in the data collection, coordinated data entry and cleaning, and contributed to writing and reviewing the manuscript.

Acknowledgement

We extend our deepest gratitude to all the women who participated in the study and our local partners who were instrumental in the logistical conduction of the study, including: Acção de Solidariedade e Saúde Comunitária (ASSC, Angola); Oswaldo Cruz Foundation (Brazil); Action Humanitaire pour la Santé et le Développement Communautaire (AHUSA-DEC, DRC); Cadre de Récupération et d'Encadrement pour l'Epanouissement Intégral des Jeunes (CREEIJ, DRC); Association pour le Soutien, l'Education, la Promotion de la Vie et des Initiatives Communautaires (ASEPROVIC, DRC); Swasti (India); Organisasi Perubahan Sosial Indonesia (OPSI, Indonesia); Bar Hostess Empowerment and Support Programme (BHESP, Kenya); Sex Workers Outreach Program (SWOP) Ambassadors (Kenya); Coast Sex Workers Alliance (COSWA, Kenya); Kisumu Sex Workers Alliance (KISWA, Kenya); Partners For Health and Development in Africa (PHDA, Kenya); Nigeria Sex Workers Association (NSWA, Nigeria); Royal Women Health and Rights Initiative (Nigeria); Initiative for Young Women’s Health and Development (Nigeria); and Mothers for the Future (South Africa). In addition, we would like to thank Mary Oschwald, MSW, Ph.D., Associate Research Professor, Portland State University, School of Social Work, Regional Research Institute for Human Development. Services, Co-PI.

Data Availability

BW affirms that the manuscript is an honest, accurate, and transparent account of the data collected,stored, and analysed. Due to ethical considerations (i.e. consent was not obtained or given for open data access oradditional data usage), controlled and secure data access and usage is necessary for subject protections. De-identifiedaggregate data used for this analysis can be requested from the corresponding author. Access permission will be considered based on the following usage criteria: (a) for the purpose of partnering on research on female sex workers; (b)for inclusion in curriculum for educational purposes; or (c) for the provision of services to female sex workers andtheir children by governmental and non-governmental organisations.

Semple SJ, Pines HA, Vera AH, Pitpitan EV, Martinez G, Rangel MG, et al. Maternal role strain and depressive symptoms among female sex workers in Mexico: the moderating role of sex work venue. Women Health. 2020;60:284–99.
Beckham SW, Shembilu CR, Winch PJ, Beyrer C, Kerrigan DL. ‘If you have children, you have responsibilities’: motherhood, sex work and HIV in southern Tanzania. https://doi.org/101080/136910582014961034 [Internet]. 2014 [cited 2023 May 23];17:165–79. https://www.tandfonline.com/doi/abs/10.1080/13691058.2014.961034
Kurtz SP, Surratt HL, Kiley MC, Inciardi JA. Barriers to health and social services for street-based sex workers. J Health Care Poor Underserved. 2005;16:345–61.
Ma PHX, Chan ZCY, Loke AY. Conflicting identities between sex workers and motherhood: A systematic review. Women Health [Internet]. 2019 [cited 2023 May 23];59:534–57. https://pubmed.ncbi.nlm.nih.gov/30040603/
Wanjiru R, Nyariki E, Babu H, Lwingi I, Liku J, Jama Z et al. Beaten but not down! Exploring resilience among female sex workers (FSWs) in Nairobi, Kenya. 2021; https://doi.org/10.1186/s12889-022-13387-3
Elsdon R, O’Shaughnessy R, Hodge SM, Murray CD. Becoming a mother in the context of sex work: Women’s experiences of bonding with their children. Health Care Women Int. 2022;43:663–85.
Willis B, Welch K, Onda S. Health of female sex workers and their children: a call for action. Lancet Glob Health [Internet]. 2016 [cited 2021 Dec 9];4:e438–9. http://www.thelancet.com/article/S2214109X16300717/fulltext
Aho J, Nguyen VK, Diakité SL, Sow A, Koushik A, Rashed S. High acceptability of HIV voluntary counselling and testing among female sex workers: impact of individual and social factors. HIV Med [Internet]. 2012 [cited 2023 May 23];13:156–65. https://pubmed.ncbi.nlm.nih.gov/22107342/
Popoola BI. Occupational Hazards and Coping Strategies of Sex Workers in Southwestern Nigeria. Health Care Women Int [Internet]. 2013 [cited 2023 May 23];34:139–49. https://pubmed.ncbi.nlm.nih.gov/23311907/
Willis B, Perttu E, Fitzgerald M, Thompson H, Weerasinghe S, Macias-Konstantopoulos W. Causes of mortality among female sex workers: Results of a multi-country study. EClinicalMedicine [Internet]. 2022 [cited 2023 May 23];52. http://www.thelancet.com/article/S2589537022003881/fulltext
Lorway R, Lazarus L, Chevrier C, Khan S, Musyoki HK, Mathenge J et al. Ecologies of security: On the everyday security tactics of female sex workers in Nairobi, Kenya. Glob Public Health [Internet]. 2018 [cited 2023 May 23];13:1767–80. https://doi.org/10.1080/17441692.2018.1442487
UN Women. In focus: Sustainable Development Goal 5 [Internet]. Web Page. 2022 [cited 2023 May 24]. https://www.unwomen.org/en/news-stories/in-focus/2022/08/in-focus-sustainable-development-goal-5
Jana S, Dey B, Reza-Paul S, Steen R. Combating human trafficking in the sex trade: can sex workers do it better? J Public Health (Bangkok) [Internet]. 2014 [cited 2023 Jun 18];36:622–8. https://dx.doi.org/10.1093/pubmed/fdt095
Kerrigan D, Kennedy CE, Morgan-Thomas R, Reza-Paul S, Mwangi P, Win KT et al. A community empowerment approach to the HIV response among sex workers: effectiveness, challenges, and considerations for implementation and scale-up. Lancet [Internet]. 2015 [cited 2023 Jun 18];385:172–85. https://pubmed.ncbi.nlm.nih.gov/25059938/
Patel SK, Mukherjee S, Mahapatra B, Battala M, Jayaram M, Kumta S et al. Enhancing financial security of female sex workers through a community-led intervention in India: Evidence from a longitudinal survey. PLoS One [Internet]. 2019 [cited 2021 May 17];14. https://pubmed.ncbi.nlm.nih.gov/31639161/
Dugas M, Bédard E, Kpatchavi AC, Guédou FA, Béhanzin L, Alary M. Structural determinants of health: a qualitative study on female sex workers in Benin. https://doi.org/101080/0954012120191595515 [Internet]. 2019 [cited 2023 May 23];31:1471–5. https://www.tandfonline.com/doi/abs/10.1080/09540121.2019.1595515
Basu A, Dutta MJ. We are mothers first: localocentric articulation of sex worker identity as a key in HIV/AIDS communication. Women Health. 2011;51:106–23.
Ali S, Chaudhuri S, Ghose T, Jana S. Examining the Role of a Community-Led Structural Intervention in Shaping Mothering Among Sex Workers in India. Feminist Inq Social Work. 2020;36:80–96.
Gorman H. Marginalisation of Immoral Women: Experiences of Young Women Street Sex Workers in Surabaya, Indonesia. Intersections: Gender and Sexuality in Asia and the Pacific [Internet]. 2011 [cited 2023 May 23];26. http://intersections.anu.edu.au/issue26/gorman.htm
Nyariki E, Wanjiru R, Shah P, Kungu M, Babu H, Weiss HA et al. Managing motherhood - the experiences of female sex workers in Nairobi, Kenya. Cult Health Sex [Internet]. 2022 [cited 2023 May 23]; https://pubmed.ncbi.nlm.nih.gov/36519798/
Parmley L, Rao A, Young K, Kose Z, Phaswana-Mafuya N, Mcingana M, et al. Female Sex Workers’ Experiences Selling Sex during Pregnancy and Post-Delivery in South Africa. Stud Fam Plann. 2019;50:201–17.
Duff P, Shoveller J, Chettiar J, Feng C, Nicoletti R, Shannon K. Sex Work and Motherhood: Social and Structural Barriers to Health and Social Services for Pregnant and Parenting Street and Off-Street Sex Workers. Health Care Women Int. 2015;36:1039–55.
Brooks-Gordon B, Morris M, Sanders T. Harm Reduction and Decriminalization of Sex Work: Introduction to the Special Section. Sex Res Social Policy. 2021;18:809–18.
The Global Network of Sex Work Projects. Angola [Internet]. Web Page. 2020 [cited 2023 May 23]. https://www.nswp.org/country/angola
Academic rigour journalistic flair. How Brazil’s sex workers have been organised and politically effective for 30 years [Internet]. Web page. 2017 [cited 2023 May 23]. https://theconversation.com/how-brazils-sex-workers-have-been-organised-and-politically-effective-for-30-years-88903
Kiernan B, Mishori R, Masoda M. ‘There is fear but there is no other work’: a preliminary qualitative exploration of the experience of sex workers in eastern Democratic Republic of Congo. http://dx.doi.org/101080/1369105820151073790 [Internet]. 2015 [cited 2023 May 23];18:237–48. https://www.tandfonline.com/doi/abs/10.1080/13691058.2015.1073790
Mbote DK, Nyblade L, Kemunto C, Giger K, Kimani J, Mingkwan P, et al. Police discrimination, misconduct, and stigmatization hhr_final_logo_alone.Indd 1 of female sex workers in kenya: Associations with delayed and avoided health care utilization and lower consistent condom use. Health Hum Rights. 2020;22:199–212.
Popoola BI. Occupational hazards and coping strategies of sex workers in southwestern Nigeria. Health Care Women Int. 2013;34:139–49.
Wheeler S. South African Leadership Makes Moves to Decriminalize Sex Work | Human Rights Watch [Internet]. Report. 2022 [cited 2023 Jun 19]. p. 3. https://www.hrw.org/news/2022/12/14/south-african-leadership-makes-moves-decriminalize-sex-work
Khan A, Hussain R. Violence against Women in Pakistan: Perceptions and Experiences of Domestic Violence. Asian Stud Rev [Internet]. 2008;32:239–53. https://doi.org/10.1080/10357820802062181
Critelli FM. Voices of resistance: seeking shelter services in Pakistan. Violence Against Women. 2012;18:437–58.
Mindell JS. Disparities, variations, inequalities or inequities: Whatever you call them, we need data to monitor them. Isr J Health Policy Res [Internet]. 2019 [cited 2023 May 24];8:1–5. https://ijhpr.biomedcentral.com/articles/10.1186/s13584-019-0307-7
Ohnishi M, Notiço E. Reduction of health-related risks among female commercial sex workers: learning from their life and working experiences. Health Care Women Int. 2011;32:243–60.
McCloskey RJ, Karandikar S, Reno R, España M. The Feminist Ethic of Care: Mothering Among Sex Workers in Mumbai. Affilia - Journal of Women and Social Work [Internet]. 2021 [cited 2021 Jun 15];36:43–61. https://journals.sagepub.com/doi/abs/10.1177/0886109920939053?journalCode=affa
Gilligan C. In a Different Voice: Women’s Conceptions of Self and of Morality. The Future of Difference [Internet]. New Brunswick, NJ: Rutgers University Press; 1985 [cited 2021 Jun 15]. p. 37.
Holkup PA, Tripp-Reimer T, Salois EM, Weinert C. Community-based Participatory Research: An Approach to Intervention Research With a Native American Community. ANS Adv Nurs Sci. 2004;27:162–75.
Hall J, Donelle L, Laliberte Rudman D, Baumann J, Weaver H, Jones R et al. It Is Important for Everyone as Humans to Feel Important, Right? Findings from a Community-Based Participatory Needs Assessment with Street-level Sex Workers. Soc Work Public Health [Internet]. 2020 [cited 2023 Jun 20];35:33–46. https://pubmed.ncbi.nlm.nih.gov/32156199/
Glaser BG, Strauss AL. Thed Discovery of Grounded Theory: Strategies for qualitative Research [Internet]. Aldine Publishing Company; 2012. https://www.google.ca/books/edition/The_Discovery_of_Grounded_Theory/rtiNK68Xt08C?hl=en&gbpv=1&dq=Glaser+B.+G.,+Strauss+A.+L.+(1967).+The+discovery+of+grounded+theory:+Strategies+for+qualitative+research.+Aldine+Transaction.&printsec=frontcover
Guida J, Hu L, Liu H. The Impact of Occupational Stigma on the Social Networks of Older Female Sex Workers: Results from a Three-Site Egocentric Network Study in China. AIDS Patient Care STDS. 2016;30:1–3.
Stangl AL, Earnshaw VA, Logie CH, Van Brakel W, Simbayi LC, Barré I et al. The Health Stigma and Discrimination Framework: a global, crosscutting framework to inform research, intervention development, and policy on health-related stigmas. BMC Med [Internet]. 2019 [cited 2023 Jul 16];17. https://pubmed.ncbi.nlm.nih.gov/30764826/
Kerrigan D, Barrington C, Perez M, Gomez H, Mbwambo J, Likindikoki S, et al. Assessing and Addressing Social Determinants of HIV among Female Sex Workers in the Dominican Republic and Tanzania through Community Empowerment-Based Responses. HHS Public Access. 2020;17:88–96.
Cange CW, LeBreton M, Saylors K, Billong S, Tamoufe U, Fokam P et al. Female sex workers’ empowerment strategies amid HIV-related socioeconomic vulnerabilities in Cameroon. Cult Health Sex [Internet]. 2017 [cited 2021 May 17];19:1053–65. https://pubmed.ncbi.nlm.nih.gov/28264630/
Kaloga M, Karandikar S, Gezinski LB, McCloskey RJ. Health Concerns and Access to Services: Female Sex Workers’ Experiences in Mumbai, India. World Med Health Policy [Internet]. 2019 [cited 2021 May 17];11:148–62. https://onlinelibrary.wiley.com/doi/full/10.1002/wmh3.298
Parmley L, Rao A, Young K, Kose Z, Phaswana-Mafuya N, Mcingana M et al. Female Sex Workers’ Experiences Selling Sex during Pregnancy and Post-Delivery in South Africa. Stud Fam Plann [Internet]. 2019 [cited 2023 Apr 7];50:201–17. https://pubmed.ncbi.nlm.nih.gov/30997677/
Parmley L, Fielding-Miller R, Mnisi Z, Kennedy CE. Obligations of motherhood in shaping sex work, condom use, and HIV care among Swazi female sex workers living with HIV. African Journal of AIDS Research [Internet]. 2019 [cited 2023 Jun 1];18:254–7. https://www.tandfonline.com/action/journalInformation?
Mastin T, Murphy AG, Riplinger AJ, Ngugi E. Having Their Say: Sex Workers Discuss Their Needs and Resources, Health Care for Women International. 2016;37:343–63. https://www.tandfonline.com/action/journalInformation?journalCode=uhcw20
Sinha S, Prasad I. Examining hopes, aspirations, and future plans of women in non-brothel-based sex work in Kolkata, India. Cult Health Sex [Internet]. 2021 [cited 2023 Jun 1];23:913–26. https://asu.pure.elsevier.com/en/publications/examining-hopes-aspirations-and-future-plans-of-women-in-non-brot
Kavanagh NM, Marcus N, Bosire R, Otieno B, Bair EF, Agot K, et al. Health and Economic Outcomes Associated With COVID-19 in Women at High Risk of HIV Infection in Rural Kenya. JAMA Netw Open. 2021;4:e2113787.
Shareck M, Buhariwala P, Hassan M, O’campo P. Helping women transition out of sex work: study protocol of a mixed-methods process and outcome evaluation of a sex work exiting program. [cited 2024 Jul 23]; https://doi.org/10.1186/s12905-020-01086-3
Rekart ML. Sex-work harm reduction. Lancet. 2005;366:2123–34.
du Plessis E, Chevrier C, Lazarus L, Reza-Paul S, Rahman SHU, Ramaiah M et al. Pragmatic women: negotiating sex work, pregnancy, and parenting in Mysore, South India. Cult Health Sex [Internet]. 2020 [cited 2023 Jun 1];22:1177–90. https://pubmed.ncbi.nlm.nih.gov/31549914/
Mbote DK, Nyblade L, Kemunto C, Giger K, Kimani J, Mingkwan P et al. Police discrimination, misconduct, and stigmatization hhr_final_logo_alone.Indd 1 of female sex workers in kenya: Associations with delayed and avoided health care utilization and lower consistent condom use. Health Hum Rights [Internet]. 2020 [cited 2021 Dec 8];22:199–212. https://doaj.org/article/e44a2fadeb4a47b1a7b70923451a24c0

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We want another job: A multi-country qualitative study on the self-reported health, social, and economic needs of female sex workers with children.

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Background

Methods

Theoretical frameworks

Study Design

Setting

Participants

Procedures

Data Analysis

Results

Individual survival and care for self

Alternative sources of income to stop or supplement sex work

Affordable and accessible maternal care and preventive healthcare

Maternal duty to provide for children

Education for FSWM children

Safety, medical and health care for FSWM children

Basic essentials for children

Safety and rights for self and children

Social respect and legal rights for sex worker mothers and children

Societal respect for children

Discussion

Limitations and Strengths

Conclusion

Declarations

Funding

Author Contribution

Acknowledgement

Data Availability

References

Additional Declarations

Status:

Version 1