UBC Faculty Research and Publications

High Lifetime Pregnancy and Low Contraceptive Usage Among Sex Workers Who Use Drugs- An Unmet Reproductive… Duff, Putu; Shoveller, Jean; Zhang, Ruth; Alexson, Debbie; Montaner, Julio S; Shannon, Kate Aug 18, 2011

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata


52383-12884_2011_Article_419.pdf [ 161.98kB ]
JSON: 52383-1.0223882.json
JSON-LD: 52383-1.0223882-ld.json
RDF/XML (Pretty): 52383-1.0223882-rdf.xml
RDF/JSON: 52383-1.0223882-rdf.json
Turtle: 52383-1.0223882-turtle.txt
N-Triples: 52383-1.0223882-rdf-ntriples.txt
Original Record: 52383-1.0223882-source.json
Full Text

Full Text

RESEARCH ARTICLE Open AccessHigh Lifetime Pregnancy and Low ContraceptiveUsage Among Sex Workers Who Use Drugs- AnUnmet Reproductive Health NeedPutu Duff1,2, Jean Shoveller2, Ruth Zhang1, Debbie Alexson3, Julio SG Montaner1,4 and Kate Shannon1,2,4*AbstractBackground: The objective of this study was to describe levels of pregnancy and contraceptive usage among acohort of street-based female sex workers (FSWs) in Vancouver.Methods: The study sample was obtained from a community-based prospective cohort study (2006-2008) of 211women in street-based sex work who use drugs, 176 of whom had reported at least one prior pregnancy.Descriptive statistics were used to estimate lifetime pregnancy prevalence, pregnancy outcomes (miscarriage,abortion, adoption, child apprehension, child custody), and contraceptive usage. In secondary analyses, associationsbetween contraceptive usage, individual and interpersonal risk factors and high number of lifetime pregnancies(defined as greater than the sample mean of 4) were examined.Results: Among our sample, 84% reported a prior pregnancy, with a mean of 4 lifetime pregnancies (median = 3;IQR: 2-5). The median age of women reporting 5+ pregnancies was 38 years old [interquartile range (IQR): 25.0-39.0] compared to 34 years [IQR: 25.0-39.0] among women reporting 4 or fewer prior pregnancies. 45% wereCaucasian and 47% were of Aboriginal ancestry. We observed high rates of previous abortion (median = 1;IQR:1-3),apprehension (median = 2; IQR:1-4) and adoption (median = 1; IQR:1-2) among FSWs who reported priorpregnancy. The use of hormonal and insertive contraceptives was limited. In bivariate analysis, tubal ligation (OR =2.49; [95%CI = 1.14-5.45]), and permanent contraceptives (e.g., tubal ligation and hysterectomy) (OR = 2.76; [95%CI= 1.36-5.59]) were both significantly associated with having five or more pregnancies.Conclusion: These findings demonstrate high levels of unwanted pregnancy in the context of low utilization ofeffective contraceptives and suggest a need to improve the accessibility and utilization of reproductive healthservices, including family planning, which are appropriately targeted and tailored for FSWs in Vancouver.BackgroundTo date, research on the sexual and reproductive healthof female sex workers (FSWs) has primarily focused onvulnerability to sexually transmitted infections (STIs),particularly HIV infection [1]. However, FSWs also maybe at high risk of pregnancy, as most are of reproductiveage and many experience frequent vaginal intercoursewithout adequate access to contraceptives [2,3]. However,the broader reproductive health and pregnancy patternsof FSWs, particularly those who use drugs, have been lar-gely neglected in research and public health interventionsglobally. Understanding the availability and use of contra-ceptives as well as pregnancy patterns among FSWs whouse drugs is essential to develop more comprehensive,women-centred reproductive health services that pro-mote positive maternal and child health and reduceadverse outcomes such as maternal mortality, unsafeabortions, the vertical transmission of HIV/AIDS, andpoor birth outcomes for children of FSWs.Access to reproductive health services, including con-traceptives, prenatal care and mothering services [4], area basic human right [5,6], and are particularly importantfor marginalized, drug-using women who may experiencehigher rates of maternal morbidity, mortality and nega-tive obstetric, fetal and child outcomes as a result of druguse during pregnancy [7-10]. While research about access* Correspondence: gshi@cfenet.ubc.ca1British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, CANADAFull list of author information is available at the end of the articleDuff et al. BMC Pregnancy and Childbirth 2011, 11:61http://www.biomedcentral.com/1471-2393/11/61© 2011 Duff et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.to reproductive health services among drug-using FSWsis scarce, a number of studies report that substance-usingmothers experience limited or no access to prenatal carebecause of the stigma attached to maternal substance useduring pregnancy [11-13]. Current child-centred policiesin Canada have also been found to pose significant bar-riers to accessing appropriate reproductive health andtreatment programs among women who use substancesduring pregnancy; many women avoid these services forfear of losing custody of their children [14]. The lack ofrecognition of the reproductive health needs and rightsof women who use drugs limits their access to appropri-ate and non-judgmental reproductive health care services[15,16]. In addition to barriers posed by their drug use,FSWs’ involvement in sex work may further limit theiraccess to reproductive health services. Police surveillanceand crackdowns have been found to displace street-basedFSWs to peripheral areas, away from health care services[17,18]. Elsewhere, a lack of targeted services, expensivetravel costs, health care service hours and sex workstigma have been identified as barriers to health andsocial services among FSWs [19], and could potentiallyrestrict access to reproductive health services and impactlevels of pregnancy and contraceptive usage amongwomen in our sample.Most previous studies on reproductive health practicesand outcomes of FSWs have been among FSWs living indeveloping countries. Our literature search yielded no stu-dies that explicitly focused on the reproductive healthneeds of street-based FSWs who use drugs in industria-lized countries. Thus, we undertook a study of street-based FSWs living in Vancouver, Canada, to: (1) describelevels of contraceptive usage, prior pregnancy and preg-nancy outcomes (including abortion, adoption, childapprehensions, miscarriage, child custody arrangements);(2) examine the correlates of having a high number ofprior pregnancies (defined as having greater than themean number of pregnancies (5+)).MethodsData were obtained from a community-based prospectivecohort of the BC Centre for Excellence in HIV/AIDS, inpartnership with a local sex work agency, Women’s Infor-mation Safe Haven (WISH) Drop-in Centre Society. Thestudy approach has been described in detail previously[20]. Briefly, between 2006 and 2008, 252 street-basedfemale sex workers were recruited using targeted outreachat solicitation spaces, based on mapping and time-locationsampling. While this was not a random sample, time-loca-tion sampling has been increasingly used as a method forrecruiting hard-to-reach populations at times and spaceswhere they congregate. The study’s eligibility criteriaincluded: self- identifying as a woman (including transgen-der), aged 14 years or older, actively engaged in street-level sex work and having used illicit drugs within the pastmonth (excluding marijuana). Participants who consentedand were enrolled in the study completed a baseline and6-monthly follow-up interview-administered question-naires by trained peer researchers (current or formerstreet-based sex workers). Additionally, nurse-adminis-tered pre-test counseling and HIV screening using Biolyti-cal Laboratories INSTI™ Rapid HIV Antibody Test(specificity 99.3%, sensitivity 99.6%) were conducted. Atbaseline, a detailed semi-structured questionnaire coveringdemographics, health service use, working conditions,violence, sexual and drug risk practices was administered.Participants received $25 remuneration for their time andexpertise. Ethical approval for this research was receivedfrom the UBC/Providence Health Ethics Review Board.Statistical AnalysesGiven our interest in lifetime pregnancy, our analyses wererestricted to responses of women of reproductive age (18-49 years) who provided a valid response to “have you everbeen pregnant”. In total, 211 women met the above cri-teria and were included in the analyses. For our analysesof contraceptive usage, the entire sample of 211 womenwas used, as contraceptive usage is a relevant measure forall FSWs in our sample. For our analyses of pregnancyoutcomes (such as adoption, custody, apprehensions andabortions), we restricted our sample to the 176 womenwho reported prior pregnancy. We excluded women whohad never been pregnant as they were not as risk for theseoutcomes.Outcomes of interestThe following pregnancy outcomes were analyzed: preva-lence of lifetime pregnancies; prevalence of abortion (aproxy of unwanted pregnancy); and miscarriage. Otherpregnancy outcomes measured included adoption, childapprehension (defined as the removal of a child from his/her mother’s custody by child protection services), has atleast one child in her custody, and at least one child is incustody of family members. The analysis also examinedthe use of various types of contraceptives during the pre-vious 6 months, including one or more of the following:barrier contraceptives only (male/female condom use);intrauterine device (IUD); hormonal contraceptives (birthcontrol pill, Depo-Provera, Norplant); and, permanentcontraceptives (tubal ligation, hysterectomy). We alsoaccounted for FSWs’ age (measured as a continuous vari-able), ethnicity, current drug use (any use of cocaine, crackcocaine, crystal methamphetamine), their exposure to‘social’ factors (e.g., “having a partner who scores drugs foryou”; having a regular partner that supports you finan-cially). In bivariate analysis, associations between indivi-dual- and interpersonal- level variables and high numberof lifetime pregnancies were examined. Higher number ofDuff et al. BMC Pregnancy and Childbirth 2011, 11:61http://www.biomedcentral.com/1471-2393/11/61Page 2 of 8lifetime pregnancies was defined as 5+ (operationalized asgreater than the mean number of 4 pregnancies, versusless than the mean). Pearson chi-squared test was used tocompare dichotomous, categorical variables and one-wayanalysis of variance (ANOVA) was used for comparison ofcontinuous variables. P-values were generated using theFisher’s test of exact probability when one or more obser-vations was less than or equal to five. We stratified preg-nancy outcomes and contraceptive use by high (5+) versuslow number of lifetime pregnancies. Variables with pvalues of < 0.1 were considered statistically significant andentered into a multivariable model. Variables were consid-ered significant in multivariable analyses with an alphacut-off of p < 0.05.ResultsOf the 211 women eligible for this study, 176 (84%)women reported ever being pregnant. The median age ofwomen reporting 5+ pregnancies was 38 years old [inter-quartile range (IQR): 25.0-39.0] compared to 34 years[IQR: 25.0-39.0] among women reporting 4 or fewer priorpregnancies. The median age of first sex work was17 years of age [IQR:15-25]. Forty-five percent were Cau-casian and 47% were of Aboriginal ancestry. Forty-seven(22%) reported being HIV positive, and 33(16%) were HIVpositive, and taking Highly Active Antiretroviral Therapy(HAART). Approximately half (49%) of the women in oursample had non-commercial, intimate partners within thelast 6 months of the interview.Drug use was prevalent among our sample, with 103(48.8%) having reported using heroin, 71 (33.7%) whoused cocaine and 53 (25.1%) having reported intensivecrack use (> 10 rocks per day) 6 months prior to the inter-view. The median age for initiation of injection drug usewas 17.5 years [IQR = 15-23], and the median age of crackcocaine use was 20 years [IQR = 16-29.8].Pregnancy and child outcomesThe mean number of lifetime pregnancies for the entiresample (n = 211) was 4, with a median of 3 [IQR = 2-5].Among FSWs who reported a prior pregnancy (n = 176),the median age of participants having 5 or more lifetimepregnancies was 38 years, compared to 34 years amongwomen who reported having 4 or less pregnancies. Thepregnancy outcomes for the 176 FSWs who reported everbeing pregnant are reported in Table 1. Among FSWswho reported at least one prior pregnancy, forty-five per-cent reported a previous miscarriage (median = 1, IQR: 1-3) and 43% reported having a previous abortion (median =1, IQR: 1-3). The proportion of women who reported hav-ing a prior miscarriage or induced abortion among theentire sample (n = 211) was 37% and 36% respectively.Thirty-two percent of women had one or more of theirchildren apprehended by Child Welfare Services (median= 2, IQR: 1-4), while 20% currently had one or more oftheir children living with them (median = 2, IQR: 1-3).Twenty-eight percent of respondents said that they hadone or more of their children being cared for by the child’sfather or another family member.The median age of initiation into sex work was higheramong women who had five or more lifetime pregnancies(median = 18;[IQR = 14-22]) compared to women whohad four or less lifetime pregnancies (median = 17; [IQR =14-25]), though they were not significantly different (p =0.92). Participants who had five or more prior pregnancieshad a higher number (median = 7) of clients per week,compared to women who had four or less pregnancies(median = 5).Birth control practicesWhile consistent condom use by clients in our sample havepreviously been found to be high(72%) [21], only 14% ofthe 211 women included in our analysis reported relyingon condoms alone as a method of birth control. Therewere no reports of female condom use in this sample. Ninepercent reported having used injectable hormones (e.g.,Depo-provera) and 1% reported that they had used thebirth control pill. The median age of FSWs using any typeof hormonal contraceptives (birth control pill, Depo-Provera, Norplant, injectable hormones) was 33 years[IQR:25-37]. Intrauterine devices (IUDs) were onlyreported by 1% of the women interviewed. Permanent con-traceptives, including tubal ligation (16.6%) and hysterect-omy (7.1%) were more common, though primarily amongolder FSWs (Median = 41 years; [IQR:36-45]) (Table 2).The median age among FSWs who did not use permanentcontraceptives was 33.0 [IQR:25.0-38.0]. Older age(age wasmeasured as a continuous variable), was significantly asso-ciated with permanent contraceptive use (p < 0.001).In bivariate analysis, FSWs who reported tubal ligationhad 2.5 greater odds of having a higher number of preg-nancies (OR = 2.49; [95%CI = 1.14-5.45]). Similarly,FSWs who reported using permanent contraceptives(e.g., tubal ligation and hysterectomy) had 2.76 increasedodds of having five or more pregnancies (OR = 2.76;[95%CI = 1.36-5.59]) compared to those who did notuse permanent contraceptives. Alternatively, female-con-trolled contraceptives were not significantly associatedwith having five or more prior pregnancies (OR = 1.62;[95%CI = 0.86-3.03]). Individual-level drug risks andinterpersonal risk factors for pregnancy (e.g., economicdependence on one’s partner or having a partner whoprocures drugs) were not significantly associated withhaving five or more prior pregnancies (Table 3).DiscussionAmong this cohort of FSWs, we found a high prevalenceof lifetime pregnancy, abortion and child apprehension,Duff et al. BMC Pregnancy and Childbirth 2011, 11:61http://www.biomedcentral.com/1471-2393/11/61Page 3 of 8and low utilization of hormonal and insertive barrier con-traceptives. On average, the women in this study reportedfour pregnancies during their lifetime, which is nearlythree times the fertility rate of the general Canadianpopulation [22].Among our entire sample of 211 FSWs, 76 (36%) abor-tions were reported (median of 1, [IQR:1-3]). The self-reported prevalence of abortions among our cohortsuggests a much higher level of unintended/unwantedpregnancy compared to the general Canadian population;the Canadian induced abortion rate is 14.1 per 1,000women aged 15-44 [23]. Despite the lack of data on abor-tions among drug-using FSWs in resource rich countries, afew studies in low and middle-income countries have alsoreported high rates of abortion among FSWs [2,24]. Forexample, a study in Colombia found that 53% of FSWsinterviewed reported having ever had an abortion [24].Results from a Kenyan survey revealed an 86% prevalenceof lifetime abortion among FSWs, with 50% of respondentsreported having more than one [25]. Abortion dataamongst the women enrolled our study are comparable tothose in low-resource settings and suggest that despitelegalized abortion and universal health care access inCanada, many women, particularly marginalized women,could benefit greatly from improved uptake of effectivecontraception and improved access to reproductive andsexual health care, including abortion services. Since ourstudy does not capture abortions post-interview, our find-ings likely underestimate the true rate of lifetime abortionsamong FSWs. Additionally, though abortion rates can beused as a proxy for unwanted pregnancy, our findingslikely underestimate the true rate, since access to abortionservices may be limited among this population.While evidence of female-controlled contraceptionamong FSWs in our setting is scant, the limited use ofcontraceptives in our study is comparable to findings inresource-poor settings [1,2,26], and may suggest lowaccess to female-controlled contraceptives and reproduc-tive health services in this setting [27]. Other studies inour setting have found low utilization of health care ser-vices in general, due to the marginalization of FSWs anddrug users, and their reluctance to use health and socialservices [27,28]. Avoidance of police and individual zon-ing restrictions (resulting from previous drug or solicita-tion charges) restrict FSWs’ access to health services [29].The high rate of child apprehension observed in our sam-ple may further act as a barrier to seeking health care andsocial services [14]. Such policies that restrict access tohealth and social services can deny FSWs of enablingenvironments necessary to exercise their reproductiverights. Low access to reproductive health and motheringservices (including antenatal care) may be of concern,considering the high rates of pregnancy among FSWs inour study. Contextual factors, such as poverty andTable 2 Contraceptive usage among 211 street-basedFemale Sex Workers (FSWs) who use drugsBarrier Contraceptive n (%)Female condom 0 (0.0)Condom only (for birth control) 30(14.2)Condoms only with clients 139 (65.8)Female-controlled Contraceptives (excluding condoms) 64 (30.3)Hormonal ContraceptiveOral contraceptive pill 2 (1.0)Intrauterine device (IUD) 3 (1.4)Depo-provera/Injection 18 (8.5)Permanent contraceptiveTubal ligation (sterilization) 35 (16.6)Hysterectomy 15 (7.1)Table 1 Pregnancy outcomes among Female Sex workers (FSWs) who use drugs and reported at least one priorpregnancyPregnancy history n = 176Median, IQRMedian number of pregnancies (entire sample, n = 211) 3 (2-5)Lifetime Pregnancy Outcomes among FSWs who reported prior pregnancy (n = 176) n (%)Median, IQRMiscarriage 79 (45)1 (1-3)Abortion 76 (43)1 (1-3)Adoption 33 (19)1 (1-2)Child Apprehension 56 (32)2 (1-4)Currently supporting a child 35 (20)2 (1-3)Child in custody of family/father 49 (28)2 (1-2)Duff et al. BMC Pregnancy and Childbirth 2011, 11:61http://www.biomedcentral.com/1471-2393/11/61Page 4 of 8Table 3 Individual- and interpersonal- level factors associated with greater number of pregnancies (5+) among street-based Female Sex Workers (FSWs) who reported prior pregnancy (n = 176), with crude Odds Ratios, 95% Confidenceintervals (95% CI) and p-values5+ pregnanciesn (%)Odds Ratio (95% CI) p - valueDemographic CharacteristicsAboriginalyes 42 (50.0) 1.49 (0.8-207) 0.19other 42 (50.0) (ref)Caucasianyes 35 (41.7) 0.75 (0.4-1.4) 0.33no 49 (58.3) (ref)Contraceptive usageCondoms only for birth control*yes 14 (17.9) 1.39 (0.6-3.2) 0.45no 64 (82.1) (ref)Female Controlled Contraceptives *yes 35 (44.3) 1.62 (0.9-3.0) 0.13no (ref)Permanent Contraceptives(Hysterectomy, Tubal ligation)*yes 30 (38.0) 2.76 (1.4-5.6) < 0.01no (ref)Hysterectomy*yes 8 (10.1) 2.37 (0.7-8.2) 0.16no (ref)Tubal Ligation*yes 22 (28.2) 2.49 (1.1- 5.5) 0.02no 56 (71.79) (ref)Intrauterine Device (IUD)*yes 0.0 (0.0) - 0.25no (ref)Hormonal Contraceptives*yes 6 (7.7) 0.44 (0.2-1.2) 0.10no (ref)Birth Control Pills*yes 0 (0.0) - 0.50no 78 (100.0) (ref)Depo-Provera*yes 6 (7.7) 0.73 (0.3-2.2) 0.60no (ref)Individual Level- Drug UseCocaine†yes 29 (34.5) 1.04 (0.6-1.9) 0.91no (ref)Heroin†yes 37 (44.0) 0.94 (0.5-1.7) 0.83no (ref)Crystal Methamphetamine†yes 6 (7.1) 0.57 (0.2-1.6) 0.28no (ref)Crack cocaine†yes 23 (27.4) 1.32 (0.6-2.2) 0.72no (ref)Duff et al. BMC Pregnancy and Childbirth 2011, 11:61http://www.biomedcentral.com/1471-2393/11/61Page 5 of 8homelessness, may reduce FSWs’ ability to travel toclinics [19], or purchase hormonal contraceptives. More-over, the instability arising from homelessness and illicitdrug use may not be conducive to hormonal contracep-tives such as the birth-control pill, which require routineand strict adherence, and annual or semi-annual pre-scription renewals. Homelessness has been associatedwith decreased access to health care services [30], andmay also limit access to contraceptives. Illicit drug usemay further exacerbate barriers to accessing contracep-tives [24], although we found that illicit drug use andeconomic dependence on one’s partner were not signifi-cantly associated with higher number of pregnancies.Additionally, perceptions of negative side effects (e.g.,physical and emotional side effects; long-term healtheffects) of hormonal contraceptives may also contributeto their low uptake [31]. Additional studies are needed toelucidate the reasons for low use of hormonal and inser-tive contraceptives among FSWs.The higher rate of condom use compared to hormonalcontraceptives, particularly among younger FSWs, mayreflect their knowledge of condoms’ dual role in preg-nancy and STI/HIV prevention. Low or no-cost condomsand their widespread availability also may contribute tothe relatively higher use of condoms compared to otherforms of contraceptives. Additionally, we found the rateof condom use (primarily by intimate/regular partners)to be much lower than the reported rate of consistentcondom use by FSWs’ clients from a previous study inour setting (72%) [21]. The low rates of condom use byintimate partners point to the need for dual protectionfrom STIs/HIV and unwanted pregnancies. Long-lasting,female-controlled contraception methods, such as inject-able hormones, may be effective in reducing unintendedpregnancy. Permanent contraceptives usage was highamong our sample, particularly tubal ligation and hyster-ectomy. The hysterectomy rate among our sample isexceptionally high when compared to the Canadian rateof 338 per 100,000 population [32]. The factorscontributing to this prevalence in our study are unclearand warrant further attention.This study has a number of limitations. The findingsfrom this study may not be generalizable to FSWs workingin other venues, such as bars, massage parlours and/orescort agencies. Given the sensitive nature of the topic,and our reliance on self-report data, the responsesobtained in this study may be subject to social desirabilitybias. However, previous studies suggest that sex workersand drug users provide truthful accounts of their sex anddrug use activities when questioned in a non-threateningenvironment [33]. Additionally, our study may underesti-mate the true rate of lifetime pregnancy and abortionamong FSWs, as pregnancies post-interview are not cap-tured. In the absence of data about pregnancy intention/desires, we used abortion rates as a proxy for unwantedpregnancy, which may limit our estimation of the true rateof unwanted pregnancy. However, induced abortion hasbeen used as a proxy for unwanted pregnancy in other stu-dies [34]. Finally, our small sample size (particularly oursample restricted to FSWs who had ever been pregnant)may have limited our statistical power to detect associa-tions with high pregnancy levels.ConclusionsThe high levels of unwanted pregnancy and underutiliza-tion of effective contraception suggests that FSWs whouse drugs may not have access to knowledge or resources,such as contraceptives or reproductive health services, thatallow them to have full control over their reproductivehealth. It is imperative to develop targeted services forFSWs that extend beyond HIV/STI prevention and com-prehensively address reproductive health needs. The coreprinciples of women-centred care, which emphasizewomen’s autonomy, empowerment, safety, diversity andcomplexity as well the importance of social context inshaping reproductive health [35], need to be considered inorder to better attend to the specific reproductive healthneeds of FSWs. Efforts to improve access and utilizationTable 3 Individual- and interpersonal- level factors associated with greater number of pregnancies (5+) among street-based Female Sex Workers (FSWs) who reported prior pregnancy (n = 176), with crude Odds Ratios, 95% Confidenceintervals (95% CI) and p-values (Continued)Methadone†yes 18 (21.4) 0.92 (0.5-1.9) 0.82no (ref)Partner procures drugsyes 23 (27.4) 1.13 (0.6-2.2) 0.72no (ref)Economic dependence on partneryes 23 (27.4) 0.96 (0.5-1.9) 0.90no (ref)* Currently Using † Used within the last six monthDuff et al. BMC Pregnancy and Childbirth 2011, 11:61http://www.biomedcentral.com/1471-2393/11/61Page 6 of 8of reproductive health services amongst this populationalso need to address other barriers, including the fear ofchild apprehension when help-seeking, particularly duringpre- and post-natal periods. Comprehensive outreachservices that include family planning and reproductivehealth services may hold promise for better serving thispopulation [21,36].AcknowledgementsThis work was supported through an operating grant from the CanadianInstitutes of Health Research (CIHR, HHP-98835). KD is supported through aCIHR and Michael Smith Foundation for Health Research (MSFHR) doctoralresearch trainee award, and MWT and JS are supported through a MSFHRSenior Scholar Awards. KS is supported through a MSFHR Scholar Award, aCIHR New Investigator Award, and National Institutes of Health Research(R01DA028648). JS is supported through a CIHR/PHAC Applied Public HealthChair in Improving Youth Sexual Health. We would like to extend our thanksto the women who participated project, including our many communitypartners, advisory board members and in particular the peer research team:Shari, Rose, Chanel, Laurie, Debbie, and Adrian. We would like toacknowledge our research and administrative staff, including Peter Vann,Ruth Zhang, Eric Fu, Ofer Amram, and Calvin Lai.Author details1British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, CANADA. 2School of Populationand Public Health, University of British Columbia, 5804 Fairview Avenue,Vancouver, BC, V6T 1Z3, CANADA. 3WISH Drop-In Centre Society, Vancouver,V6B 1S5, BC CANADA. 4Department of Medicine, University of BritishColumbia, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z1Y6, CANADA.Authors’ contributionsPD and KS designed the study. RZ conducted the statistical analysis. PDwrote the first draft of the manuscript and integrated suggestions from KS,JS and RZ. All authors made significant contributions to the conception anddesign of the analyses, interpretation of the data, and drafting of themanuscript, and all authors approved the final manuscript.Competing interestsThe authors declare that they have no competing interests.Received: 6 May 2011 Accepted: 18 August 2011Published: 18 August 2011References1. Delvaux T, Crabbé F, Seng S, Laga M: The need for family planning andsafe abortion services among women sex workers seeking STI care inCambodia. Reprod Health Matters 2003, 11:88-95.2. Feldblum PJ, Nasution MD, Hoke TH, Van Damme K, Turner AN, Gmach R,Wong EL, Behets F: Pregnancy among sex workers participating in acondom intervention trial highlights the need for dual protection.Contraception 2007, 76:105-110.3. Chacham AS, Diniz SG, Maia MB, Galati AF, Mirim LA: Sexual andReproductive Health Needs of Sex Workers: Two Feminist Projects inBrazil. Reproductive Health Matters 2007, 15:108-118.4. Gable L, Gostin LO, Hodge JG: HIV/AIDS, reproductive and sexual health,and the law. Am J Public Health 2008, 98:1779-1786.5. Cook RJ: International human rights and women’s reproductive health.Stud Fam Plann 1993, 24:73-86.6. UNFPA: Supporting the Constellation of Reproductive Rights. [http://www.unfpa.org/rights/rights.htm].7. Wolfe EL, Davis T, Guydish J, Delucchi KL: Mortality risk associated withperinatal drug and alcohol use in California. J Perinatol 2005, 25:93-100.8. Broekhuizen FF, Utrie J, Van Mullem C: Drug use or inadequate prenatalcare? Adverse pregnancy outcome in an urban setting. Am J ObstetGynecol 1992, 166:1747-1754, discussion 1754-1756.9. Minozzi S, Amato L, Vecchi S, Davoli M: Maintenance agonist treatmentsfor opiate dependent pregnant women. Cochrane Database Syst Rev 2008,CD006318.10. Shankaran S, Lester BM, Das A, Bauer CR, Bada HS, Lagasse L, Higgins R:Impact of maternal substance use during pregnancy on childhoodoutcome. Semin Fetal Neonatal Med 2007, 12:143-150.11. Shankaran S, Bauer CR, Bada HS, Lester B, Wright LL, Das A: Health-careUtilization among Mothers and Infants Following Cocaine Exposure.J Perinatol 0000, 23:361-367.12. Maupin R, Lyman R, Fatsis J, Prystowiski E, Nguyen A, Wright C, Kissinger P,Miller J: Characteristics of women who deliver with no prenatal care.J Matern Fetal Neonatal Med 2004, 16:45-50.13. Pagnini DL, Reichman NE: Psychosocial factors and the timing of prenatalcare among women in New Jersey’s HealthStart program. Fam PlannPerspect 2000, 32:56-64.14. Greaves L, Varcoe C, Poole N, Morrow M, Johnson J, Pederson A, Irwin L: Amotherhood issue: discourses on mothering under duress. Ottawa: Statusof Women Canada; 2002.15. Flavin J, Paltrow LM: Punishing Pregnant Drug-Using Women: DefyingLaw, Medicine, and Common Sense. Journal of Addictive Diseases 2010,29:231.16. Roberts SCM, Pies C: Complex Calculations: How Drug Use DuringPregnancy Becomes a Barrier to Prenatal Care. Matern Child Health J 2010.17. Shannon K: Mapping violence and policing as an environmental-structural barrier to health service and syringe availability amongsubstance-using women in street-level sex work. Int J Drug Policy 2008,19:140-7.18. Wood E, Kerr T, Small W, Jones J, Schechter MT, Tyndall MW: The impact ofa police presence on access to needle exchange programs. J AcquirImmune Defic Syndr 2003, 34:116-8.19. Kurtz S, Surrat H, Kiley M, Inciardi J: Barriers to Health and Social Servicesfor Street-Based Female Sex Workers. Journal of Health Care for the Poorand Underserved 2005, 16(2):345-61.20. Shannon K, Bright V, Allinott S, Alexson D, Gibson K, Tyndall MW:Community-based HIV prevention research among substance-usingwomen in survival sex work: The Maka Project Partnership. Harm ReductJ 2007, 4:20.21. Deering K, Kerr T, Tyndall MW, Montaner JSG, Gibson K, Irons L, Shannon K:A peer-led mobile outreach program and increased utilization ofdetoxification and residential drug treatment among female sex workerswho use drugs in a Canadian setting. Drug and Alcohol Dependence 2001,113:46-54.22. Statistics Canada: The Daily, Monday, July 31, 2006. Births.[http://www.statcan.gc.ca/daily-quotidien/060731/dq060731b-eng.htm].23. Statistics Canada: Induced Abortion Statistics.[http://dsp-psd.pwgsc.gc.ca/Collection/Statcan/82-223-X/82-223-XIE.html].24. Bautista CT, Mejía A, Leal L, Ayala C, Sanchez JL, Montano SM: Prevalenceof lifetime abortion and methods of contraception among female sexworkers in Bogota, Colombia. Contraception 2008, 77:209-213.25. Elmore-Meegan M, Conroy RM, Agala CB: Sex Workers in Kenya, Numbersof Clients and Associated Risks: An Exploratory Survey. ReproductiveHealth Matters 2004, 12:50-57.26. Todd CS, Alibayeva G, Sanchez JL, Bautista CT, Carr JK, Earhart KC:Utilization of contraception and abortion and its relationship to HIVinfection among female sex workers in Tashkent, Uzbekistan.Contraception 2006, 74:318-323.27. Weber AE, Tyndall MW, Spittal PM, Li K, Coulter S, O’Shaughnessy MV,Schechter MT: High pregnancy rates and reproductive health indicatorsamong female injection-drug users in Vancouver, Canada. Eur JContracept Reprod Health Care 2003, 8:52-58.28. Spittal PM, Bruneau J, Craib KJP, Miller C, Lamothe F, Weber AE, Li K,Tyndall MW, O’Shaughnessy MV, Schechter MT: Surviving the sex trade: acomparison of HIV risk behaviours among street-involved women in twoCanadian cities who inject drugs. AIDS Care 2003, 15:187-195.29. Shannon K, Strathdee SA, Shoveller J, Rusch M, Kerr T, Tyndall MW:Structural and Environmental Barriers to Condom Use Negotiation WithClients Among Female Sex Workers: Implications for HIV-PreventionStrategies and Policy. American Journal of Public Health 2009, 99:659-665.30. Aidala AA, Lee G, Abramson DM, Messeri P, Siegler A: Housing need,housing assistance, and connection to HIV medical care. AIDS Behav2007, 11:101-115.Duff et al. BMC Pregnancy and Childbirth 2011, 11:61http://www.biomedcentral.com/1471-2393/11/61Page 7 of 831. Guendelman S, Denny C, Mauldon J, Chetkovich C: Perceptions ofhormonal contraceptive safety and side effects among low-incomeLatina and non-Latina women. Matern Child Health J 2000, 4:233-239.32. Canadian Institutes for Health Information, 2010. Health Indicators[https://secure.cihi.ca/estore/productFamily.htm?pf=PFC1435&lang=en&media=0].33. Needle R, Weatherby N, Brown B, Booth R, Williams M, Watters J,Andersen M, Chitwood D, Fisher D, Cesari H, Braunstein M: The reliabilityof self-reported HIV risk behaviors of injection and non-injection drugusers. Psychology Addictive Behaviour 1995, 9:242-250.34. Kaye DK, Mirembe FM, Bantebya G, Johansson A, Ekstrom AM: Domesticviolence as a risk factor for unwanted pregnancy and induced abortionin Mulago Hospital, Kampala, Uganda. Tropical Medicine & InternationalHealth 2006, 1:90-101.35. Midmer DK: Does family-centered maternity care empower women? Thedevelopment of the woman-centered childbirth model. Fam Med 1992,24:216-221.36. Poole N: Evaluation Report of the Sheway Project for High Risk Pregnantand Parenting Women. Vancouver, British Columbia: British ColumbiaCentre of Excellence for Women’s Health; 2000.Pre-publication historyThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2393/11/61/prepubdoi:10.1186/1471-2393-11-61Cite this article as: Duff et al.: High Lifetime Pregnancy and LowContraceptive Usage Among Sex Workers Who Use Drugs- An UnmetReproductive Health Need. BMC Pregnancy and Childbirth 2011 11:61.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitDuff et al. BMC Pregnancy and Childbirth 2011, 11:61http://www.biomedcentral.com/1471-2393/11/61Page 8 of 8


Citation Scheme:


Citations by CSL (citeproc-js)

Usage Statistics



Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            async >
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:


Related Items