Experiences with Pregnancy Among Female Sex Workers in Ethiopia

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APRIL 2015 study brief inform thedevelopment ofprograms andpoliciesthatpromote ductive in Ethiopiawillprovide information history to important obtained. Anexploration offemaleservices sex workers’ repro Ethiopian female sex workers’ pregnanciesorthematernal health We know ofnoexisting studiesthatdescribetheoutcomesof and prevention ofmother-to-child transmission(PMTCT) services. their children’sfathers; orwhether they accessantenatal care tinued working during theirpregnancies;relationshipswith there ismuchto belearnedaboutwhether andhow they con texts inwhichthey get pregnantandhave children.For example, nancy amongfemale sex workers, little isknown aboutthecon Although survey datashedlightonthehighprevalence ofpreg- prohibited by law. asacommercialers activity, butthesaleofsex by women isnot In Ethiopia,itisillegalto operate abrothel orprocure sex work of 1.9 percent amongwomen. from 15 percent to 33percent, compared to nationalprevalence workers found thatHIVprevalence inthe10 studysites ranged with non-paying suchasboyfriends orhusbands. sexual partners workers, inconsistent women reported condomuse,particularly are atheightened riskofunintended pregnancy. age, female sex workers wishingto delay orlimitchildbearing Furthermore, sincemostfemale sex workers areofreproductive nated apregnancy. female sex workers and13.7 percent hadgiven hadtermi birth, - Ethiopian female sex workers. Inthe2014 survey, abouthalfof suggest thatunprotected sex andpregnancy arecommonamong able population. policies typicallyhave emphasized HIVprevention inthis vulner increasingly entering thesex trade.Publichealthprograms and an female sex workers isgrowing, withyounger women andgirls EXPERIENCES WITHPREGNANCYAMONG 2 A2014 studyof3,882Ethiopianfemale sex FEMALE SEXWORKERS INETHIOPIA: 1 Research suggeststhatthenumberofEthiopi 3 Inaseparate studyofAdama Cityfemale sex A LINKUPEXPLORATORY STUDY 3,4

5 Available data The Miz-Hasab Research Center Addis Ababa, Ethiopia ------6 violence. for womensocial services whoexperience and respondto suchabuse;andpsycho officials; peer-led mobilization to prevent including sensitizationoflaw enforcement comprehensive andmultisectoral response, a rangeofperpetrators. Thisdemands a Female sex workers experience violenceby services. care,andsafe abortion and postpartum pills, antenatal care,safe delivery, postnatal pregnancy testing, emergencycontraceptive sential reproductive suchas healthservices that female sex workers have accessto es vention andcare,programs shouldensure In additionto emphasizing HIVandSTI pre- services. prevention ofmother-to-child transmission ing theirneedfor maternal healthcareand sex late into theirpregnancies,underscor Pregnant sex workers continueto often sell and non-paying sexual partners. tion—should bepromoted withboth paying combined withother effective contracep Consistent condomuse—eitheraloneor KEY MESSAGES promoted withallsexual partners. Consistent condomuseshouldbe - - - -

©BENJAMIN CHESTERTON\DUCKRABBIT\INTERNATIONAL HIV/AIDS ALLIANCE the comprehensive health and well-being of female houses, and the street as their primary places of sex sex workers. work employment. Seventeen female sex workers were from Adama City, and the rest had migrated Under the Link Up project, a global consortium led from other cities in the country. by the International HIV/AIDS Alliance, the Pop- ulation Council, in collaboration with Miz Hasab The key informant participants consisted of three Research Center and local Link Up implementing peer educators; five NGO staffers; and three local partner, Organization for Social Services for AIDS health officials. (OSSA), conducted a qualitative study to explore Ethiopian female sex workers’ reproductive health KEY FINDINGS histories as well as their experiences with pregnancy, childbearing, and motherhood. Use of condoms and non-barrier modern contraception All participants stated that they used condoms, but STUDY METHODOLOGY with variable consistency. A recurring theme was In September and October 2014, trained interview- that female sex workers were very diligent about ers conducted hour-long in-depth interviews with using condoms with paying clients, but did not use 30 female sex workers who were receiving services condoms with intimate partners (often referred to at the OSSA office in Adama City; and 10 key as balukas). Although nearly all said that they felt informants who had experience with or expertise confident in their ability to insist on condom use on the sexual and reproductive health needs of with clients, many feared the negative reaction Adama female sex workers. The key informants they would receive from intimate partners if they included nongovernmental organization (NGO) staff, were to ask that they use condoms. Women often local health officials, and peer educators. Eligible mentioned love as another reason for not using female sex workers were aged 18 years and older condoms with intimate partners. and had ever been pregnant. The digitally recorded interviews covered the circumstances under So, if I do not use condoms one day and ask which female sex workers have become pregnant; [my lover] to use another day, he may think pregnancy outcomes; and maternal health something else. He may quarrel with me. We behaviors. Interviews were conducted in Amharic, may separate. And, since I love him, I do not transcribed and translated into English, and want that. Once we do not use condoms, we analyzed by three researchers. This brief presents stick to it. We all do this. preliminary analysis of themes related to Adama City female sex workers’ experiences with pregnancy —Sex worker, age 29 and childbearing. Since he loves me and I love him, we do not think about condoms. STUDY POPULATION —Sex worker, age 25 The 30 female sex worker participants were between the ages of 18 and 35 years, and they had They ask us for short-term birth control completed between four and 10 years of education. method, but we advised them to use con- Twenty-four had at least one living child, and 13 had doms all the time with any of their clients a current intimate partner. Participants reported as well as their balukas. However, they go having been pregnant between one and five times. without condom with their balukas. For that, Fourteen women had terminated a pregnancy, they worry about unexpected pregnancy. and three of those women had had three or more —Key informant, NGO staffer abortions. Participants reported hotels, liquor

2 │ Experiences with Pregnancy among Female Sex Workers in Ethiopia Both key informant and sex worker participants The injectable and implant were popular non- voiced a strong opinion that women currently selling barrier modern methods among contraceptive sex work did not wish to have children; pregnancies users, who felt that using these methods was more among female sex workers are virtually always unin- convenient than having to remember to take a daily tended. Frequently mentioned reasons participants pill. Some also mentioned that they liked that they gave for wishing to avoid pregnancy included: fear of did not menstruate when using these contraceptive giving birth to a child without knowing the father’s methods; their work was not interrupted by their pe- identity; concerns about whether they could con- riods each month. The most commonly cited sourc- tinue to work while pregnant; and unwillingness to es of information about family planning were local raise a child while selling sex. When asked whether NGO programs and peer educators. female sex workers worry about pregnancy, one key informant responded: Among the eight women who were not currently using a non-barrier method, common reasons Yes. Where can we deliver? We live in bars. included their beliefs that they were at low risk of There are different questions that come to pregnancy; that it was not convenient to obtain the sex worker’s mind. For instance, the child methods; that they did not like the side effects; may ask for his/her father. In addition, or that they were not comfortable with the idea of business will get decreased if a sex worker using them. becomes pregnant. For that, sex workers don’t want to get pregnant at all. I became very fat due to the birth control method that I took. I was advised by a physi- —Key informant, peer educator cian to stop taking injection since it can be a In addition to condoms, 22 sex workers were cur- cause for [high] blood pressure. rently using a non-barrier modern contraceptive —Sex worker, age 30 method (i.e., injectable, pill, or implant). These women clearly articulated their rationales for using Of course, I didn’t try any of the contracep- two methods, often explaining their decisions in tives; they are disgusting like the implant. terms of the need to prevent pregnancy with inti- —Sex worker, age 19 mate partners while also protecting themselves from disease transmission with clients. Another Emergency contraceptive pills common reason was to have back-up protection Most participants had heard of emergency against pregnancy in the event of condom failure or contraceptive pills (brand name Postpill), and they forced sex. felt that they knew where to obtain them if needed (e.g., pharmacies, NGOs, family planning I use condoms for making business, where- clinics). Some stated that the method was available as the implant is to protect pregnancy since free of charge in clinics, while others mentioned I go without condom with my boyfriend. paying between 2 and 47 birr in pharmacies —Sex worker, age 26 (between US$.10 and $2.32).*

Condoms may break. Some people may However, participants’ knowledge of this postcoital rape me without a condom. I do not want to method’s effectiveness was not always accurate. get pregnant here. I have to protect myself. One woman mentioned that emergency contracep- —Sex worker, age 20 tive pills were only effective within the first three

*US$1.00 = 20.28 ETB as of February 2015.

A Link Up Exploratory Study │ 3 hours after unprotected sex, but most believed that But this [father] is my client; he told me that they needed to be taken within 24 or 72 hours. he would support me. I don’t know what will happen. [T]here is a pill that should be taken within —Sex worker, age 28 24 hours after unprotected sex. I have never seen or used it but I heard it’s like a pill and Sex work while pregnant women used it when they go without protec- Eighteen of the 30 participants reported that they tion. A majority of the sex workers have boy- had continued sex work while pregnant, with several friends and they don’t use condoms, instead describing having sex with clients into their seventh they use Postpill after intercourse. or eighth month of pregnancy. They described varied —Sex worker, age 26 reactions by clients, some of whom expressed a preference for pregnant sex workers. Six women reported that they had ever used emergency contraceptive pills. Their reasons for using Some [clients] did not care. Some would feel them included condom breakage, lack of contracep- sorry for you, give you some money and walk tive use, and forced sex. away. Some ask you why you are doing this while pregnant. When I met my current lover, I stopped tak- —Sex worker, age 26 ing the injections. One day we had sex without condoms. We had taken some drinks I was very anxious. I did not want [clients] to and we were in the mood. I knew it was the press me hard. Some clients understand my time I could get pregnant. Then I went to feelings, but some others don’t. Marie Stopes, which is nearby to where I live. The sister counseled me and gave me —Sex worker, age 20 Postpill. When our uterus is big, many [clients] leave —Sex worker, age 26 the non-pregnant sex workers and come to us. Yes, one day a guy forced me to have sex without protection. I didn’t want to get preg- —Sex worker, age 23 nant. I had to take Postpill, so I took it. Maternal health care utilization —Sex worker, age 24 Most of the participants said that they had received at least some antenatal care during their Current pregnancies pregnancies, including HIV testing. They were Three of the 30 women were pregnant at the time of familiar with where they could access maternal the interview, all unintended pregnancies. One had health services, and their primary motivations for gotten pregnant by a client, one by a boyfriend, seeking antenatal care and PMTCT services was and one by an ex-boyfriend. Two of the three had out of concern for the welfare of their children. had unprotected sex, but one reported that she had Although those who received antenatal care typically been on the pill and was unaware of how she could delivered in facilities, some delivered at home with have gotten pregnant. unskilled attendants such as relatives or neighbors. It was unintended. I was taking medicine [pills] and I didn’t know I was pregnant until I was four months pregnant. —Sex worker, age 25

4 │ Experiences with Pregnancy among Female Sex Workers in Ethiopia I found out when I was three months preg- Some women also attempted to abort using tradi- nant. I went to the hospital and they told me tional methods suggested by friends. Two women that I was pregnant and I had follow ups for mentioned attempting to terminate a pregnancy by the rest of the time and I also got checked taking “ampicillin tablets with Coca Cola.” In one for HIV. But, I gave birth at home. case, the participant, aged 35 years, related how —Sex worker, age 22 she had paid someone in her village who could “abort it for you traditionally; it almost killed me.” During my first delivery, my labor was painful This same woman ended up requiring postabor- and stayed for about a week. However, tion care at a hospital. A similar story was told by a during my second delivery, even I had no 22-year-old participant: time to go to health facility so I delivered at home with my aunt’s assistance. Somebody took me to this lady and I lied and told her that I was only four months —Sex worker, age 24 pregnant…. But the procedure was really painful and it took days after days and she Abortion experience gave me glucose for days and sent me Fourteen women had terminated at least one home. I was about to die and friends con- pregnancy. The abortion methods used included tributed money and sent me to Marie Stopes surgical and medication abortions in facilities, and they thought I was going to die but I frequently mentioning Marie Stopes International survived. clinics. Among those who obtained surgical or medication abortions in facilities, they expressed Female sex workers living with HIV satisfaction with the experience. They reported Four of the participants were living with HIV. One paying fees ranging from 100 to 1,000 birr (roughly had gotten pregnant since the time of the positive US$5 to $50).* diagnosis, and her child has been diagnosed with HIV. She felt that vertical transmission could have They gave me a tablet. I took the tablet and been prevented had she been more knowledgeable I was told to come back after three days. about available PMTCT services. When I came back the third day, they insert- ed a tablet into my womb. I didn’t feel any One of my children is now 9 years old and pain. she lives with the virus. This is because I —Sex worker, age 19 gave birth at home and breastfed her without knowing anything. The reason for abortion is that sex workers —Sex worker, age 35 do not know who the father is. Apart from this, they cannot perform their job being Three of the four women living with HIV were on pregnant. Therefore, when sex workers want antiretroviral therapy (ART). The one who was not to abort their pregnancies, there is Marie on medication stated that she found ART to be too Stopes in our town to offer such services. inconvenient, so she had discontinued use. The We make Marie Stopes our partner. For three ART users did not mention difficulties with that, we send sex workers to get abortion treatment adherence, but one declared that she service. There are some sex workers who do did not use non-barrier contraception because she not know where to go for the same, so we believed that ART should not be combined with any inform them where to go for abortion. other medication. —Key informant, NGO staffer

A Link Up Exploratory Study │ 5 I take ART. Taking another medicine will [My daughter] doesn’t ask me what I am bring me harm. My body has adopted the doing. She thinks I am selling tella (local medicine. I went to see a doctor and I don’t drink). But she asks me where I am going. I use other medicines. even tell the lady who takes care of my chil- —Sex worker, age 30 dren that I work at a factory at night. —Sex worker, age 23 All four women said that they used condoms consis- tently with clients; they expressed a strong sense of My younger daughter was so smart; so she obligation to protect the health of their clients. One asked me how I am getting money. She said, reported that she used two condoms at a time as ‘Mommy your clothes are clean because an extra precaution, insisting that this is effective as you didn’t perform any household chores, long as the condoms are applied correctly. Another so how did you get the money? From where woman spoke about clients trying to have unpro- did you bring us money?’ I told her I cleaned tected sex despite their awareness of her positive rooms at the hotel and I get paid for that. status. —Sex worker, age 35

Some of them will tell me that since have A universal theme among sex workers who are started taking ART, there is no problem. But mothers was a strong sense of commitment to pro- the virus I have and the virus in the other viding for their children, despite their unhappiness person are different, so using condoms is a working in the sex trade. When asked about their must. desire to quit sex work, many framed their exit strat- —Sex worker, age 35 egy in terms of the welfare of their children. On one hand, they did not want to quit until they had anoth- Despite their diligence about using condoms with er way of earning money to support their children. clients, some felt that they could not use condoms On the other hand, they felt an urgency to get out with their boyfriends; these intimate partners often of sex work in order to shield their children from the refused to use condoms. negative aspects of their jobs.

[My boyfriend] knows that I am HIV positive. My son will start primary school after three I told him but he didn’t care, so I thought he years, so I don’t want to see my son be is also HIV positive. insulted at school due to my work. I was —Sex worker, age 35 among the best students. I dropped out from school due to my pregnancy. Besides, I Motherhood and sex work raised my son being tested by different chal- The circumstances under which participants lenges. So, I don’t want to see my son being became mothers varied, but a commonly expressed unhappy. For that, I will surely quit sex work. sentiment was the challenge of working as a —Sex worker, age 20 female sex worker with children. They mentioned their struggles with finding child care, with many I will quit sex work for the sake of my child’s opting to pay neighbors or landlords to watch their life. I started sex work since I had no option. children. Others reported that their children live with But now I have fulfilled the needs of my son relatives. They frequently mentioned their concerns and I have saved 20 to 30 birr per day in about their children discovering what their mothers the form of iqub (traditional savings mecha- did for a living, particularly in cases when they see nism). ...I want to quit sex work soon. clients in their homes. —Sex worker, age 30

6 │ Experiences with Pregnancy among Female Sex Workers in Ethiopia Experiences of violence for unintended pregnancy were inconsistent or nonexistent contraceptive use—condoms or Several women described experiences of violence otherwise. This risky behavior was particularly at the hands of lovers, clients, and law enforcement pronounced with intimate partners. While it is officers. The reported incidents included beatings, encouraging that participants exhibited high levels rape, and verbal abuse. In some cases, women of knowledge about HIV prevention and family were beaten when trying to insist that a client or planning, this knowledge did not always translate boyfriend use a condom. Physical and verbal abuse into consistent, correct method use. were accompanied by theft in some cases, with men either stealing from the women or refusing to pay Most women had heard of emergency contraceptive after sex. pills, but none were aware of current guidance that the method could be effective up to 120 hours after I thought he would carry condoms. At the unprotected sex, rather than the frequently cited time, I was too ashamed to ask men if they effectiveness window of 72 hours.7 Peer educators had condoms. I didn’t know such things and health care providers should make efforts to then. When it was clear he wanted to have update this guidance. In cases where pregnant sex sex without condoms, we started struggling. workers elect to terminate their pregnancies, pro- Then I cried for help, when he started hitting gram staff and health care providers should ensure me. that these women receive information on where they —Sex worker, age 25 can obtain safe abortion care.

There are plenty of such events here. Not so Violence is a pervasive problem among sex work- much by our clients but it is the police who ers, often a manifestation of the stigma and gender harass us a lot on the streets. They ask us inequity that these women face as a marginalized to give them money. They take all what we community. Many women expressed a sentiment of have done during the night. All sex workers helplessness and resentment towards law enforce- are condemned as thieves if there is one ment officials who did not offer them protection or sex worker who steals something. Some- assistance. The range of perpetrators mentioned times there is gang raping and nothing is included intimate partners, clients, and police men, done about it. many of whom may not typically be reached by HIV prevention programming for sex workers. To prevent —Sex worker, age 23 and address violence among female sex workers, a comprehensive multisectoral response is necessary PROGRAM IMPLICATIONS AND that could include peer mobilization, psychosocial RECOMMENDATIONS counseling, and sensitization of police officers. Study participants recruited at the site of Link Up partner OSSA had access to sex worker-friendly Although the common sentiment expressed in this services, and it was evident that they were aware of exploratory study was that female sex workers did and had access to critical sexual and reproductive not wish to become pregnant while selling sex, health education and care. Use of condoms and previous studies among indicate that the desire to non-barrier modern contraception was common prevent pregnancy is not universal among female among participants, but many also had experienced sex workers. In either case, health care providers unintended pregnancy and abortion. Despite high and programs that serve these women should levels of recognition of the negative consequences respect their individual rights and desires regarding of unprotected sex, the most common reasons childbearing, recognizing that both childbearing and pregnancy prevention are legitimate choices.

A Link Up Exploratory Study │ 7 Programs that serve these women should make 3Ethiopian Public Health Institute, Ethiopian Public concerted efforts to ensure access to pregnancy Health Association, Centers for Disease Control and testing, antenatal care and PMTCT, safe conception Prevention, Federal HIV/AIDS Prevention and Con- counseling, and safe delivery services. trol Office. 2014. Ethiopian National Key Population HIV Sero-behavioral surveillance (NHSBS) Round 1 Reproductive health and maternal health content Progress Report. Addis Ababa. should be integrated into HIV prevention program- 4 ming for female sex workers, with an emphasis on Central Statistical Agency [Ethiopia] and ICF Inter- recognizing and upholding their SRHR. Programs national. 2012. Ethiopia Demographic and Health such as OSSA’s represent a promising platform on Survey 2011. Addis Ababa, Ethiopia and Calverton, which to build comprehensive sexual and repro- Maryland, USA: Central Statistical Agency and ICF ductive health offerings for Adama City female sex International. workers. 5Wilcher, R., W. Cates, Jr, and S. Gregson. 2009. “Family planning and HIV: strange bedfellows no REFERENCES longer,” AIDS 23(Suppl 1): S1–6.

6 1Article 634: The Criminal Code of the Federal Mooney, A. et al. 2013. “Work-related violence and Democratic Republic of Ethiopia (Proclamation No. inconsistent condom use with non-paying partners 414/2004) 2004. among female sex workers in Adama City, Ethiopia,” BMC Public Health 13: 771. 2Overs, C. et al. 2011. “Sex work in Ethiopia: Map- 7 ping the impact of law, policy and enforcement World Health Organization. 2012. Emergency con- practices.” Paulo Longo Research Initiative. Michael traception: fact sheet no. 244. Available at: http:// Kirby Centre for Public Health and Human Rights, www.who.int/mediacentre/factsheets/fs244/en/. Monash University.

Link Up aims to improve the sexual and reproductive health and rights (SRHR) of one million young people affected by HIV across five countries in Africa and Asia. The project is being implemented by a consortium of partners led by the International HIV/AIDS Alliance. Link Up consortium partners • ATHENA Network • STOP AIDS NOW! • Global Youth Coalition on HIV/AIDS • Alliance Burundaise Contre le SIDA in Burundi • International HIV/AIDS Alliance • Organisation for Support Services for AIDS (OSSA) in Ethiopia • Marie Stopes International in Bangladesh, Myanmar and Uganda • Alliance Myanmar • Population Council • Community Health Alliance Uganda Other key collaborators include UNFPA, UNESCO and AIDS Fonds. Funded by the Ministry of Foreign Affairs of the government of the Netherlands (BUZA). To follow the progress of Link Up, visit www.link-up.org

The Population Council confronts critical health and development issues—from stopping the spread of HIV to improving reproductive health and ensuring that young people lead full and productive lives. Through biomedical, social science and public health research in about 50 countries, the Council works with our partners to deliver solutions that lead to more effective policies, programs, and technologies to improve lives worldwide. Established in 1952 and headquartered in New York, the Council is a nongovernmental, nonprofit organization with an international board of trustees.

Suggested citation: Population Council, Miz-Hasab Research Center, and Organization for Social Services for AIDS. 2015. “Experiences with pregnancy among female sex workers in Ethiopia: A Link Up exploratory study,” Link Up Study Brief. Washington, DC: Population Council. www.popcouncil.org