A MIXED METHOD STUDY ON BARRIERS IN REPRODUCTIVE HEALTH SERVICE DELIVERY FOR AND SERVICE UTILIZATION BY THE FEMALE SEX WORKERS OF BANGLADESH : TRANSLATING FINDINGS TO POLICY BRIEF

Abstract

Background There is an increasing trend in the Female Sex Workers (FSWs) population in many Asian countries, as women are often entering the sex trade at younger ages than in the past. In Bangladesh, a small country in Asia, approximately 74000 FSWs are operating in brothel, hotel, and residence or on the streets. These FSWs are most at risk of mortality and morbidity related to sexual and reproductive health (SRH) which include HIV/AIDs, STIs, and unsafe abortion including other maternal health problems. This study aimed to document SRH related practices by FSWs, particularly on contraceptives, abortion, pregnancy, use of maternal healthcare services and sexually transmitted infections (STIs) and the barriers FSWs in Bangladesh face with regard to accessing SRH care, and to assess the satisfaction with the healthcare received with the aim of developing recommendations for action. Methods A mixed method study comprising of qualitative and quantitative methods of data collection had been implemented between March 2015 and September 2016 in Dhaka city of Bangladesh where community based drop-in-centers (DICs) were operating for STI/HIV prevention intervention among FSWs. The study population included street, hotel and/or residence based FSWs of reproductive age (15-49 years). It also included policy makers, researchers and key personnel of organizations which were currently providing services for female sex workers including DIC staffs. About 731 FSWs were surveyed using a stratified sampling technique. About 14 in-depth interviews with FSWs and 9 in-depth interviews with service providers were also conducted. A workshop with 23 participants consisted of policy makers, researchers, program implementers was conducted to formulate recommendations. SRH-related service utilization rates and reported barriers faced in service utilization were main outcome variables. Descriptive statistics, Pearson’s Chi-Square and Fisher’s Exact test, one way ANOVA analysis were used for quantitative data analysis. Atlas-ti data management software and content analysis was done for qualitative data analysis. Result Of 731 FSWs interviewed, 45% were 25 to 34 years old, 45% had no education and64% were married. Around half of the respondents had a daily income of 600 BDT (7.6 US$)or less per day. About 47% of them were living in residential while around one-fourth of them live on the street. About 36.8% respondents were involved in sex trade for 3 to 7 seven years. The majority (71.4%) of the FSWs were engaged in sex act for 4 or more times per day. Greater proportions (91%) of FSWs were using short acting methods, condom (71%), oral pill (21%) and injection (16%). The reported use of long acting and permanent methods (LAPM) - Intra-uterine device (IUD) (1.5%), implant (4.7%) or female sterilization (4.5%) was very low (11%). About 61.3% of 731 FSWs reported SRH-related experiences in the past one year, including abortion (15.5%), ongoing pregnancy (9.0%), childbirth (8.3%) or any symptoms of STIs (41.6%). Among FSWs who had an abortion (n=113), the most common methods included menstrual regulation through manual vacuum aspiration (47.8%), followed by Dilation and Curettage procedure (31%) and oral medicine from pharmacies (35.4%). About 57.5% of 113 cases reported post abortion complications. Among FSWs with delivery in the past year (n=61), 27.7% attended the recommended four or more antenatal care visits and more than half did not have any postnatal visit. Of 731 FSWs, 353 (51%) reported facing barriers when seeking sexual and reproductive healthcare. Financial problems (72%), shame about receiving care (52.3%), unwillingness of service providers to provide care (39.9%), unfriendly behavior of the provider (24.4%), and distance to care (16.9%) were mentioned as barriers. Only one-third of the respondents reported an overall satisfaction score of more than fifty percent (a score of between 9 and16) with formal healthcare. Inadequacy or lack of SRH services and referral problems (e.g., financial charge at referral centers, unsustainable referral provision, or unknown location of referral) were reported by the qualitative participants as the major barriers to accessing and utilizing SRH care. Adopting sustainable and effective strategies to provide accessible and adequate SRH services for FSWs was prioritized by workshop participants. Conclusion and recommendations There was substantial unmet need for SRH care among FSWs in urban areas in Dhaka, Bangladesh. Therefore, it is important to integrate SRH services for FSWs in the formal healthcare system or integration of abortion and maternal healthcare services within existing HIV prevention services.