Maternal health service utilization and birth outcomes among female sex workers in the Democratic Republic of the Congo, Kenya, and Nigeria: results from a cross-sectional survey

Background Information on maternal health service utilization among female sex workers (FSW) in low- and middle-income countries (LMIC) is limited, with research focusing on HIV. Despite most FSW being mothers, little is known about their childbirth care or birth outcomes. To our knowledge, this is the first multicountry study to describe adverse birth outcomes among FSW in LMIC. Methods This cross-sectional study used a convenience sample of 853 FSW from eight cities in the Democratic Republic of the Congo (DRC), Kenya, and Nigeria to examine antenatal care (ANC) utilization, substance use during pregnancy, skilled birth attendance, and birth outcomes (stillbirth, perinatal mortality, and low birth weight). Self-reported outcomes for the five years preceding data collection were compared descriptively with national survey data for urban women to provide context. Results Maternal health service utilization and birth outcomes varied widely by country. FSW participants in Kenya reported high ANC utilization (95.6%) and facility delivery (97.0%), comparable to urban women. ANC utilization and facility delivery were lower among FSW participants in the DRC (ANC: 49.0%; facility delivery: 68.0%) and Nigeria (ANC: 37.5%; facility delivery: 26.1%) compared to urban women. Cost and stigma were the main barriers. Alcohol use during pregnancy was common in all countries. Stillbirth rates among participating FSW were very high (113 per 1000 births in the DRC [95% CI 85–146], 49 in Kenya [95% CI 30–75], and 85 in Nigeria [95% CI 63–111]), as was perinatal mortality. Low birth weight prevalence was high in the two countries with sufficient birthweight data (DRC: 17.1%; Kenya: 9.7%). Conclusions In this study sample, adverse birth outcomes—high stillbirth and perinatal mortality and low birth weight—may reflect the combined effects of limited access to quality maternal health services (MHS) and broader social, economic and health vulnerabilities documented among FSW populations. Kenya’s subsidized maternal healthcare system may contribute to higher MHS utilization and better birth outcomes observed in Kenya. Improving equity in maternal and newborn health for FSW requires increasing access to quality MHS and addressing underlying social determinants of health. FSW should be recognized as a high-risk population requiring targeted maternal health interventions.