Pregnancy planning and utilization of maternal health services by female sex workers in Uganda

Abstract

Introduction Globally, Female Sex workers (FSWs) face various challenges in utilizing sexual and reproductive health (SRH) services. The challenges in utilizing the existing health services in public facilities include stigma, discrimination, and policy limitations. Among the many components of comprehensive SRH services along the continuum of care that FSWs should access is pregnancy planning. The "Continuum of Care" concept for reproductive, maternal, newborn, child, and adolescent health fosters delivery of integrated comprehensive services for mothers and children before conception to delivery, postnatal, childhood and adolescence. Pregnancy planning and utilization of maternal health services (MHS) by Female sex workers (FSWs) remain obscure. In Uganda, programs accessed by FSWs have largely focused on preventing abortion and HIV management. Hitherto, little is known about the extent to which FSWs plan their pregnancies and utilize the MHS in Uganda. The study objective of this doctoral thesis was to validate the London Measure of Unplanned Pregnancies (LMUP) tool and to investigate factors associated with pregnancy planning and utilization of maternal health services among FSWs in Kampala, Uganda Methodology This study was conducted among FSWs attending Most At-Risk Population Initiative (MARPI) Clinics in Mulago, Gulu, Mbarara and Mbale through four related sub-studies, I, II, III and IV. • Sub study I, focused on the validation of the LMUP tool through cognitive interviews and psychometric testing. The LMUP was translated to Luganda. • Sub study II was a cross-sectional survey to assess pregnancy planning intensity and utilization of MHS among FSWs in Uganda. Data was collected using the adapted xiv LMUP tool. • Sub-study III was an exploratory qualitative study that sought FSWs perspectives on pregnancy planning and related practices. • Sub-study IV: Exploration of FSWs` perspectives on pregnancy planning processes and experiences Quantitative data were captured using EpiData and analyzed using STATA, while qualitative data were analyzed using the Altlas.ti computer software. Results The Luganda version of the LMUP was acceptable, and the scale was well targeted. Reliability testing revealed good internal consistency (alpha = 0.82) and acceptability (weighted kappa = 0.78). Validity testing confirmed the unidimensional structure of the measure. Likewise, with the Acholi, Lugisu, and Runyankole translations, psychometric properties assessment showed that there were no missing data, Cronbach’s alpha was>0.70, and all items loaded onto one component. Among the 819 study participants, 11% had planned their pregnancies. In the final model, higher odds of pregnancy planning were associated with not being raped, with an Odds ratio (OR) =1.68 and 95% Confidence interval (CI):1.10-2.58; non-substance abuse (OR =1.52, 95% CI: 1.09-2.10). Among the 318 FSWs who had given birth within two years of the study, 25.2% (80) utilized all the three services (antenatal, facility-based delivery and postnatal) and this was categorized as the recommended package. Forty-eight percent (151) had moderate utilization (i.e., had used only two services), while 27.3 % (87) utilized limited or no services (one or no service used). Factors that influenced the utilization of the recommended package compared to “limited/no xv service package” were having a planned pregnancy (adjusted RRR (aRR) = 3.87; 95 % CI = 1.40-10.67); Knowledge of the need to have at least four ANC visits (aRR = 2.43; 95 % CI = 1.22-4.87);Previous criminalization for sex work (aRR = 2.48; 95 % CI = 1.30-4.74); having a positive attitude towards health providers, (aRR = 2.63; 95 % CI = 1.37-5.07). Qualitatively, the notion of pregnancy planning was new to the FSWs. Most FSWs had had unplanned pregnancies due to inconsistent use of contraceptives and condoms amidst consumption of alcohol and drug abuse. Complacence in condom use was observed among FSWs who had used HIV Pre- Exposure prophylaxis (PreP) intervention. The FSWs felt protected by PreP against HIV transmission. Conclusion The Luganda version of the LMUP has now been validated, as a tool to assess pregnancy planning among sex workers in Uganda. The LMUP can be used to evaluate and refocus interventions that can help reduce unplanned pregnancies among FSWs in Uganda. The level of planned pregnancies was low, and the use of unreliable contraceptive methods was common among FSWs in Uganda. There was complacency in the use of condoms due to the misconception that PreP, is sufficient on its own. If this misconception is not addressed, it presents risks of escalated prevalence of unplanned pregnancies, HIV, and other sexually transmitted infections. I hence recommend inclusiveness in the delivery of adequate comprehensive maternal reproductive health services. Non-discriminatory MHS approaches are needed, in addition to measures that mitigate the self-stigma among FSWs.