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Background: Research has paid limited attention to understanding factors that are associated with unmet contraceptive needs among female sex workers. In order to fill this knowledge gap, we estimated the prevalence of unmet contraceptive needs and examined associated factors among FSWs in semi urban Blantyre, Malawi. Methods: We used systematic sampling to recruit 290 female sex workers in semi urban Blantyre between February and March 2019. In this cross sectional study, we used questionnaire interviews to collect quantitative data. We calculated the mean and standard deviation for continuous variables and proportions for categorical variables to describe the data. Logistic regression analysis was used to investigate the association between unmet needs (the outcome variable) and explanatory variables such as: having a steady partner, fear of contraceptives’ side effects and having a history of sexually transmitted infections. Results: Out of the 290 study participants 102 (35.2%) reported unmet contraceptive needs. The following factors were significantly associated with unmet contraceptive needs in multivariate analysis: female sex workers’ history of physical and sexual violence by clients [OR 3.38, 95% CI (1.10, 10.43)], p < 0.03, participants with a steady partner [OR 3.28, 95% CI (1.89, 5.68)], p < 0.001, and participants who feared side effects of contraceptives [OR 2.99, 95% CI (1.73, 5.20)], p < 0.001. Conclusion: Reproductive Health services should address barriers to contraceptives use for instance: violence by female sex workers’ clients, fear and misinformation on contraceptives. There is need to improve awareness of contraceptives. Specific health promotion interventions on female sex workers engaged in a steady partnership are recommended. It is important to enhance the knowledge, attitudes, and counseling skills of health care providers in order to address unmet contraceptive needs among female sex workers in semi-urban Blantyre. Plain English summary: Unmet contraceptive needs are defined as lack of contraceptives use in heterosexually active women of childbearing age who do not wish to become pregnant. Unmet contraceptive needs are the main cause of short inter-pregnancy intervals, early childbearing, physical abuse, unintended pregnancy, poor maternal and child health outcomes. Several studies have documented low contraceptives use among female sex workers (FSWs), but research has paid limited attention to understanding factors associated with unmet contraceptive needs among this population in semi urban Blantyre Malawi. In order to fill this knowledge gap, we estimated the prevalence of unmet contraceptive needs and examined factors that were associated with unmet contraceptive needs among FSWs in semi urban Blantyre, Malawi. We recruited 290 FSWs and collected quantitative data. These data were analyzed to obtain descriptive statistics. Logistic regression analysis was used to investigate the association between unmet contraceptive needs (the outcome variable) and explanatory variables such as: FSWs with history of physical and sexual violence by clients, having a steady partner, fear of contraceptives’ side effects and having a history of sexually transmitted infections. Out of the 290 FSWs, 35% reported unmet contraceptive needs. The following factors were significantly associated with unmet contraceptive needs in multivariate analysis: FSWs’ history of physical and sexual violence by clients, participants with a steady partner and participants who feared contraceptive side effects. Sexual and Reproductive Health services should address barriers to contraceptives use, female sex workers exposure to violence, having a steady partners and concerns about side effects. There is also a need to improve the knowledge, attitudes, and counseling skills of health providers in order to address unmet contraceptive needs among FSWs.
The study was conducted between February and March 2019. In this cross sectional study, we collected quantitative methods on unmet contraceptive needs and preferences among FSWs in four semi urban townships of Blantyre (Chirimba, Lunzu, Kachere, Mbayani) of southern Malawi. The following inclusion criteria were used: self-reported female sex workers aged between 18 and 49 years and consented for the study. We used the following exclusion criteria: female sex workers participating in another study or coming from outside the study locations, and FSWs who were sick. The sample size was calculated using single population proportion formula. We used 25% as the prevalence of FSWs with unmet contraceptive needs [23], with a margin error of 5%, and at 95 level of confidence. Thus the required sample size was 288. At each of the four sites, data collection took place at places mutually agreed by the study team and research participants. About 75 FSWs from each site were systematically selected to participate in the study (we recruited FSWs who arrived at the study site on even days of the month). A specific period was identified within which the questionnaires were completed by the research assistants through the interview process. Female research assistants trained in data collection and research went to each site at a pre-arranged time. They explained the purpose of the study and emphasized the fact that FSWs who do not wish to participate may either leave, or remain as study participants, but they will not be adversely affected by their voluntary decisions if they decided not to participate. Following the explanation, study participants were given an opportunity for them to ask questions and get clarifications. Data were collected on: socio-economic/demographic background of the informant, contraceptive preferences, access to contraceptives and preference of contraceptives providers. One of the strengths of this study was the sample size of almost 300 FSWs which was used to explore several variables independently associated with unmet contraceptive needs. Secondly the study used validated questions on contraceptive use that are also employed by Malawi Demographic and Health Survey (MDHS) which will facilitate comparison to other literature. Each of the FSWs was asked questions by the research assistants and the survey questionnaires were completed by the data collectors. Cash reimbursement of Malawi Kwacha (MK) 1,500 (approximately 2 US$ at the time of data collection) was paid to all study participants as compensation for their time in the study. Data analysis was conducted in Stata 14.1 (Stata Corporation, College Station, TX, USA). Descriptive statistics were calculated from general socio-economic and demographic characteristics of the study participants. Logistic regression analysis was used to investigate the relationship between unmet contraceptive needs (the outcome) and hypothesized explanatory variables. Characteristics of participants were analyzed using frequency summaries and are presented as percentages. Age was summarized using median and interquartile range. Table Table11 indicates the variables which were summarized. Note that steady partner attitude on contraceptives has two categories: FSWs with and without steady partners. The numbers and percentage of each category including the category of FSWs without steady partners were summarized in the baseline characteristics (Table (Table1).1). However, when performing univariate analysis to assess associations between the outcome and the independent variables, the category of FSWs without steady partners was excluded as the output from such a category did not have a meaningful interpretation with respect to associations with baseline variables. Characteristics of female sex workers in semi – urban Blantyre 2019 (N = 290) a Median and IQR have been reported In this study consistent condom use was defined as using condoms correctly for every act of penile-vaginal sex [24]. Regular alcohol intake was defined as having a minimum of one drink per day. This refers to the amount consumed on any single day and is not intended as an average over several days [25]. Steady partner was defined as spouse or cohabiting partner or someone with a romantic relationship with for a long period of time [24]. The study was approved by the University of Malawi’s COMREC (College of Medicine Research and Ethics Committee). Certificate number P.07/18/2444, dated 08-Sept-2018. Blantyre District Office approved the study. We got clearance from the group village headmen before the study started. All study staff were carefully trained in human subjects’ protection, especially the importance of protecting privacy and confidentiality and obtaining informed consent from each study participant using the approved consent forms. Participants were informed of their right to withdraw from the study and not to answer any questions they felt uncomfortable with. All the information which was provided by the participants was treated with confidentiality.
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