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Background Behavioural and structural factors related to sex work, place female sex workers (FSWs) at high risk of maternal mortality and morbidity (MMM), with a large portion due to unintended pregnancies and abortions. In the African context where MMM is the highest in the world, understanding the frequency and determinants of pregnancy and abortion among FSWs is important in order to meet their sexual and reproductive health needs. Methods Data from two Beninese cross-sectional surveys among FSWs aged 18+ (2013, N = 450; 2016, N = 504) were merged. We first performed exploratory univariate analyses to identify factors associated with pregnancy and abortion (p < 0.20) using Generalized Estimating Equations with Poisson regression and robust variance. Multivariate analyses first included all variables identified in the univariate models and backward selection (p ≤ 0.05) was used to generate the final models. Results Median age was 39 years (N = 866). The proportion of FSWs reporting at least one pregnancy during sex work practice was 16.4%, of whom 42.3% had more than one. Most pregnancies ended with an abortion (67.6%). In multivariate analyses, younger age, longer duration in sex work, previous HIV testing, having a boyfriend and not using condoms with him were significantly (p < 0.05) associated with more pregnancies. Conclusion One FSW out of five had at least one pregnancy during her sex work practice. Most of those pregnancies, regardless of their origin, ended with an abortion. Improving access to various forms of contraception and safe abortion is the key to reducing unintended pregnancies and consequently, MMM among FSWs in Benin.

INTRODUCTION The behavioural and structural factors related to sex work, place female sex workers (FSWs) at high risk of maternal mortality and morbidity (MMM), with a large portion due to unintended pregnancies and abortions. In the African context where MMM is high amongst the general population, understanding the frequency and determinants of pregnancy and abortion among FSWs is important in order to meet their sexual and reproductive health needs. METHODS Data from two Beninese cross-sectional surveys (2013 - 2016) were merged. We first performed exploratory univariate analyses to identify factors associated with pregnancy and abortion (p<0.20) using Generalized Estimating Equations with Poisson regression and robust variance. Multivariate analyses first included all the variables identified in the univariate models and backward selection (p≤0.05) was used to generate the final models. RESULTS Mean age was 31 years (N=866). The proportion of FSWs reporting at least one pregnancy during sex work was 16.4%, of whom 42.3% had more than one. Most pregnancies ended up with an abortion (67.6%). FSWs who lived with their boyfriend (adjusted proportion ratio (aPR) = 1.74, 95%CI: [1.1, 2.8]) and did not use condoms consistently with them (aPR=1.83, 95%CI: [1.1, 3.0]) had more pregnancies. CONCLUSION One FSW out of five had at least one pregnancy during her sex work practice. Most of those pregnancies, regardless of their origin, ended up with an abortion. Improving access to various forms of contraception and safe abortion is the key to reducing unwanted pregnancies and consequently, MMM among FSWs in Benin.

Background The intention of becoming pregnant has an evident impact on the prenatal and postnatal period. For female sex workers (FSWs) in West Africa, among whom pregnancies are frequent as are HIV and sexually transmitted infections, a better understanding of their pregnancy intention and its influence on pregnancy occurrence could help prevent unwanted pregnancies and adverse effects on wanted pregnancies. Methods We recruited 330 FSWs in Benin and 322 in Mali and followed them for 12 months. We evaluated their pregnancy intention at recruitment and 6-month follow-up, using a multidimensional prospective measure that we developed. We assessed pregnancy occurrence with a pregnancy test and a retrospective questionnaire at 6 and 12 months. A Cox proportional hazard model was used to estimate the association between intention and pregnancy. We carried out an analysis to take losses to follow-up into account using the inverse of probability of censoring weights and a cluster analysis to corroborate that the multidimensional measure of pregnancy intention fitted the data. Results 407 FSWs were included in the first 6-month analysis and 284 at 12 months. Mean age was 30.9 years. The pregnancy intention distribution was similar between the two periods: 15.2% in the first period and 16.3% in the second had a positive intention. One out of four were ambivalent and almost 60% (57.7% and 56.3%) had a negative intention. For 38.2% of the FSWs, the intention changed between the two periods. The global incidence rate (to first event) was 19.1 pregnancies per 100 person-years. There was a borderline significant trend (p = 0.0529) of decreased pregnancy incidence with decreasing intention. Compared to positive intention, the adjusted hazard ratio (aHR) for ambivalent and negative intentions were 0.71 [95% confidence interval (95% CI) 0.32–1.60] and 0.46 (95% CI 0.21–1.01), respectively. Conclusion The level of pregnancy intention influences its occurrence among FSWs and nearly one out of six wants a baby despite working in the sex trade. Programmatically, early identification of these women could facilitate provision of quality antenatal and postnatal care. Given other health risks associated with sex work this care may decrease potential risks of adverse maternal, fetal and neonatal outcomes.