Among this cohort of FSWs, we found a high prevalence of lifetime pregnancy, abortion and child apprehension, and low utilization of hormonal and insertive barrier contraceptives. On average, the women in this study reported four pregnancies during their lifetime, which is nearly three times the fertility rate of the general Canadian population .
Among our entire sample of 211 FSWs, 76 (36%) abortions were reported (median of 1, [IQR:1-3]). The self-reported prevalence of abortions among our cohort suggests a much higher level of unintended/unwanted pregnancy compared to the general Canadian population; the Canadian induced abortion rate is 14.1 per 1,000 women aged 15-44 . Despite the lack of data on abortions among drug-using FSWs in resource rich countries, a few studies in low and middle-income countries have also reported high rates of abortion among FSWs [2, 24]. For example, a study in Colombia found that 53% of FSWs interviewed reported having ever had an abortion . Results from a Kenyan survey revealed an 86% prevalence of lifetime abortion among FSWs, with 50% of respondents reported having more than one . Abortion data amongst the women enrolled our study are comparable to those in low-resource settings and suggest that despite legalized abortion and universal health care access in Canada, many women, particularly marginalized women, could benefit greatly from improved uptake of effective contraception and improved access to reproductive and sexual health care, including abortion services. Since our study does not capture abortions post-interview, our findings likely underestimate the true rate of lifetime abortions among FSWs. Additionally, though abortion rates can be used as a proxy for unwanted pregnancy, our findings likely underestimate the true rate, since access to abortion services may be limited among this population.
While evidence of female-controlled contraception among FSWs in our setting is scant, the limited use of contraceptives in our study is comparable to findings in resource-poor settings [1, 2, 26], and may suggest low access to female-controlled contraceptives and reproductive health services in this setting . Other studies in our setting have found low utilization of health care services in general, due to the marginalization of FSWs and drug users, and their reluctance to use health and social services [27, 28]. Avoidance of police and individual zoning restrictions (resulting from previous drug or solicitation charges) restrict FSWs' access to health services . The high rate of child apprehension observed in our sample may further act as a barrier to seeking health care and social services . Such policies that restrict access to health and social services can deny FSWs of enabling environments necessary to exercise their reproductive rights. Low access to reproductive health and mothering services (including antenatal care) may be of concern, considering the high rates of pregnancy among FSWs in our study. Contextual factors, such as poverty and homelessness, may reduce FSWs' ability to travel to clinics , or purchase hormonal contraceptives. Moreover, the instability arising from homelessness and illicit drug use may not be conducive to hormonal contraceptives such as the birth-control pill, which require routine and strict adherence, and annual or semi-annual prescription renewals. Homelessness has been associated with decreased access to health care services , and may also limit access to contraceptives. Illicit drug use may further exacerbate barriers to accessing contraceptives , although we found that illicit drug use and economic dependence on one's partner were not significantly associated with higher number of pregnancies. Additionally, perceptions of negative side effects (e.g., physical and emotional side effects; long-term health effects) of hormonal contraceptives may also contribute to their low uptake . Additional studies are needed to elucidate the reasons for low use of hormonal and insertive contraceptives among FSWs.
The higher rate of condom use compared to hormonal contraceptives, particularly among younger FSWs, may reflect their knowledge of condoms' dual role in pregnancy and STI/HIV prevention. Low or no-cost condoms and their widespread availability also may contribute to the relatively higher use of condoms compared to other forms of contraceptives. Additionally, we found the rate of condom use (primarily by intimate/regular partners) to be much lower than the reported rate of consistent condom use by FSWs' clients from a previous study in our setting (72%) . The low rates of condom use by intimate partners point to the need for dual protection from STIs/HIV and unwanted pregnancies. Long-lasting, female-controlled contraception methods, such as injectable hormones, may be effective in reducing unintended pregnancy. Permanent contraceptives usage was high among our sample, particularly tubal ligation and hysterectomy. The hysterectomy rate among our sample is exceptionally high when compared to the Canadian rate of 338 per 100,000 population . The factors contributing to this prevalence in our study are unclear and warrant further attention.
This study has a number of limitations. The findings from this study may not be generalizable to FSWs working in other venues, such as bars, massage parlours and/or escort agencies. Given the sensitive nature of the topic, and our reliance on self-report data, the responses obtained in this study may be subject to social desirability bias. However, previous studies suggest that sex workers and drug users provide truthful accounts of their sex and drug use activities when questioned in a non-threatening environment . Additionally, our study may underestimate the true rate of lifetime pregnancy and abortion among FSWs, as pregnancies post-interview are not captured. In the absence of data about pregnancy intention/desires, we used abortion rates as a proxy for unwanted pregnancy, which may limit our estimation of the true rate of unwanted pregnancy. However, induced abortion has been used as a proxy for unwanted pregnancy in other studies . Finally, our small sample size (particularly our sample restricted to FSWs who had ever been pregnant) may have limited our statistical power to detect associations with high pregnancy levels.