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. 2023 Jan 30;20(1):25.
doi: 10.1186/s12978-023-01565-4.

Longitudinal study of pregnancy intention and its association with pregnancy occurrence among female sex workers in Benin and Mali

Gentiane Perrault Sullivan  1   2   3 , Fernand Aimé Guédou  4   5 , Fatoumata Korika Tounkara  6 , Luc Béhanzin  4   5   7 , Nana Camara  8 , Marlène Aza-Gnandji  5 , Bintou Dembele Keita  8 , Odette Azonnadou  5 , Ismaila Thera  8 , Lisa Avery  9 , Michel Alary  6   4   10
Affiliations

Longitudinal study of pregnancy intention and its association with pregnancy occurrence among female sex workers in Benin and Mali

Gentiane Perrault Sullivan et al. Reprod Health. .

Abstract
in English, French

Background: The intention of becoming pregnant has an evident impact on the prenatal and postnatal period. For female sex workers (FSWs) in West Africa, among whom pregnancies are frequent as are HIV and sexually transmitted infections, a better understanding of their pregnancy intention and its influence on pregnancy occurrence could help prevent unwanted pregnancies and adverse effects on wanted pregnancies.

Methods: We recruited 330 FSWs in Benin and 322 in Mali and followed them for 12 months. We evaluated their pregnancy intention at recruitment and 6-month follow-up, using a multidimensional prospective measure that we developed. We assessed pregnancy occurrence with a pregnancy test and a retrospective questionnaire at 6 and 12 months. A Cox proportional hazard model was used to estimate the association between intention and pregnancy. We carried out an analysis to take losses to follow-up into account using the inverse of probability of censoring weights and a cluster analysis to corroborate that the multidimensional measure of pregnancy intention fitted the data.

Results: 407 FSWs were included in the first 6-month analysis and 284 at 12 months. Mean age was 30.9 years. The pregnancy intention distribution was similar between the two periods: 15.2% in the first period and 16.3% in the second had a positive intention. One out of four were ambivalent and almost 60% (57.7% and 56.3%) had a negative intention. For 38.2% of the FSWs, the intention changed between the two periods. The global incidence rate (to first event) was 19.1 pregnancies per 100 person-years. There was a borderline significant trend (p = 0.0529) of decreased pregnancy incidence with decreasing intention. Compared to positive intention, the adjusted hazard ratio (aHR) for ambivalent and negative intentions were 0.71 [95% confidence interval (95% CI) 0.32-1.60] and 0.46 (95% CI 0.21-1.01), respectively.

Conclusion: The level of pregnancy intention influences its occurrence among FSWs and nearly one out of six wants a baby despite working in the sex trade. Programmatically, early identification of these women could facilitate provision of quality antenatal and postnatal care. Given other health risks associated with sex work this care may decrease potential risks of adverse maternal, fetal and neonatal outcomes.

RéSUMé: L’intention de devenir enceinte a un impact évident sur les périodes pré- et post-natales. Les grossesses, tout comme le VIH et les infections transmises sexuellement, sont fréquentes chez les femmes travailleuses du sexe (FTS) en Afrique. Une meilleure compréhension de leur intention de grossesse et l’influence de celle-ci sur leur survenue pourrait aider à prévenir les grossesses non désirées et les effets indésirables lors de grossesses désirées. Des FTS ont été suivies pendant 12 mois (N = 330 Bénin - N = 322 Mali). L’intention d’avoir une grossesse a été évaluée au recrutement et à 6 mois, à l’aide d’une mesure multidimensionnelle prospective développée pour l’étude. La survenue de grossesse a été mesurée à l’aide d’un test d’urine et d’une question rétrospective à 6 et 12 mois. Un modèle des risques proportionnels de Cox a été utilisé pour estimer l’association entre l’intention et la grossesse. Un poids égal à l’inverse de probabilité de sélection a été appliqué pour prendre en compte les femmes perdues au suivi et une analyse hiérarchique par grappe pour valider la mesure de l’intention a été effectuée. 407 FTS (âge moyen 30.9 ans) ont été incluses dans la première période d’analyse et 284 dans la deuxième. Au cours de ces deux périodes, un peu plus de 16% des FTS avaient une intention positive. Une FTS sur 4 était ambivalente et près de 60% avaient une intention négative. Pour 38.2% des FTS, l’intention a changé entre les deux périodes. Le taux d’incidence était de 19.1 grossesses par 100-personne-années. Comparées aux FTS avec une intention positive de grossesse, celles ambivalentes ou avec une intention négative, ont eu moins de grossesses, respectivement 30% [rapport de risque ajusté (RRa) = 0.71, intervalle de confiance à 95% (IC 95%) 0.32–1.60) et 54% (RRa = 0.46, IC 95% 0.21–1.01) moins de grossesses. Chez les FTS l’intention d’avoir ou non une grossesse en influence l’occurrence. De plus, près d’une femme sur six désire une enfant dans les six prochains mois malgré la pratique du travail du sexe. Identifier ces femmes et les accompagner lors de la conception et des périodes pré- et post-natales pourrait aider à réduire les effets indésirables.

Keywords: Pregnancy incidence; Pregnancy intention; Reproductive health; Sex workers; Sub-Saharan Africa.

Plain language summary

The intention of becoming pregnant has an evident impact on the prenatal and postnatal period. For female sex workers (FSWs) in West Africa, among whom pregnancies are frequent, a better understanding of their pregnancy intention and its influence on pregnancy occurrence could help prevent unwanted pregnancies and adverse effects of wanted pregnancies. We recruited 330 FSWs in Benin and 322 in Mali and we followed them for 12 months. We evaluated their pregnancy intention at recruitment and at 6-month follow-up. We assessed pregnancy occurrence with a pregnancy urine test and with a retrospective questionnaire asking on pregnancy occurrence at 6 and 12 months. With these data we estimated the association between intention and pregnancy. 407 FSWs were included in the first 6-month analysis and 284 at 12 months. Sixteen percent of the FSWs had a positive intention of having a pregnancy in the next 6 months in both the first 6-month and 12 months. One out of four were ambivalent and almost 60% had a negative intention. For 38.2% of the FSWs the intention changed between the two periods. Women with an ambivalent intention compared to those with positive intention, had 30% less pregnancies whereas for negative intention, women had 54% less pregnancies during the study follow-up. As for any woman, the level of pregnancy intention influences its occurrence. Moreover, nearly one out of six FSWs wants a baby despite working in the sex trade. Programmatically, early identification of these women could facilitate provision of quality antenatal and postnatal care.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Flow chart of recruitment and follow-up. * 3 women with missing value for the intention were also lost to follow-up and are not included in the lost to follow-up box. ** Had at least one pregnancy during the first 6 months. *** Including the 407 women included in the 6-month analysis and 18 women with missing values at recruitment but still retained at the 6-month follow-up visit. **** 13 women with a missing value for the intention were also lost to follow-up and are not included in the lost to follow-up box
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