A report titled Causes of mortality among female sex workers: Results of a multi-country study was recently published in The Lancet. The research identifies maternal death as the most common cause of mortality among Female Sex Workers (FSW).
The research is a part of a larger exploratory study conducted between January 16, 2019, and October 1, 2019, across eight countries – Angola, Brazil, The Democratic Republic of the Congo (DRC), India, Indonesia, Kenya, Nigeria, and South Africa.
The selection of the countries was done based on different factors inclusive of a large number of FSW, high prevalence of maternal deaths, or high maternal mortality rate, high HIV infection rates among FSW, presence of local partner organisations, and contribution of the overall geographic regional diversity of the study.
Along with the study being the first multi-country study that focuses on the Female Sex Workers (FSW) mortality rate and its causes, it is also the single largest study on FSW deaths ever reported.
1280 FSW participants from across eight countries reported the death of 2112 FSWs that occurred between January 2014 and September 2019. The majority of deaths (57.9 percent) occurred in 2019 and the largest percentage of deaths (57.9 percent) were among women aged between 20-29.
The study used Community Knowledge Approach (CKA) method which was validated in a study that identified maternal, neonatal, and jaundice-related deaths among women living in a community with an 80-100 percent sensitivity.
CKA is useful in studies that lack official data and is relied on the detailed information provided by community elders or organisations like local sex worker organisations (SWOs) and NGOs in this case. Based on the data collected through CKA methods in the eight countries and 2112 FSWs, the study found that abortion was the main cause of mortality resulting in 35.5 percent of total deaths between 2014 and 2019.
The study also highlights that most of the abortion-related deaths occurred in women aged 20-29 (62.4 percent) as compared to 19.6 percent among 11-19 years old girls.
While abortion was identified as the leading cause of death, other maternal causes constituted of 16.6 percent, followed by 13.6 percent of deaths by suicide. Though HIV/AIDS is usually the most highlighted cause of death among FSWs, the percentage of HIV/AIDS-related deaths in this study is 7.9 percent compared to 12.5 percent for murder and 11.6 percent for unclassified causes.
According to the study, the deaths of the FSWs affected the lives of about 3659 children who lost their mothers. The report also further classifies the location of death where the cause is maternal. It is shocking to know that more than 50 percent of the death occurred in the place where women lived or worked as compared to the hospitals or on the way to the hospitals.
The existing studies on female sex workers have focused on causes of morbidity whereas there are only a few studies on FSW causes of mortality. The prominent reason for the same is FSW not being identified in official registries and the incomplete civil registry and vital statistics data in low and middle-income countries.
In India, the study collected data from four places including Nashik, Hyderabad, Warangal, and Gudibanda. While some previous studies in India have highlighted that female sex workers have the highest rates of HIV infection while little was known about their mortality rate due to this, the new report shows that around 20.5 percent of deaths occur due to HIV/AIDS in FSW in India.
Although maternal death (32.6 percent) is seen as the main cause of FSW deaths in India, there are a significant number of deaths that occur due to death by suicide (11.4 percent), death by murder (16.7 percent), accidents (7.6 percent), tuberculosis (3 percent), deaths by murder (16.7 percent), and cancer (2 percent).
Among the causes of maternal death, the majority of female sex workers died due to abortion (44.2 percent), followed by (20.9 percent) death by suicide while pregnant. Though there was 4.7 percent of suicide-related deaths, deaths due to HIV and hemorrhage were 2.3 percent and 4.7 percent respectively.
The result of the study not only highlights the lack of information available for the mortality among FSW but also the need for the countries to introduce programs preventing FSW deaths. The study also throws light on the lack of studies on the female sex workers in India. Sex workers are the “least well investigated population” and there are no studies included in FSW studies in the standardised all-cause mortality ratio meta-analysis.
It’s of utmost importance for the governments to ensure the inclusion of female sex workers in the official records. It will not only help conduct more in-depth studies on the condition of sex workers in India, but also provide them with all the required facilities.
Distance to healthcare services, limited financial means, fear of being exposed, lack of confidentiality, and discriminatory treatment by healthcare workers are some of the challenges faced by the FSW.
These factors act as a big hindrance for them to even access the sexual and reproductive healthcare facilities like contraception that can lead to unplanned pregnancies and increased morbidity and mortality ratio resulting from complications of unsafe abortion.
Access to safe abortion and availability of affordable contraception is crucial in preventing unplanned pregnancies among FSW and considering the significant number of abortion related deaths showcased in the study, it’s also immensely necessary for FSW to have access to safe abortions and post-abortion care.
The need of the hour is to create a safe and more accessible environment for female sex workers, which can help reduce the mortality rate among them due to poor healthcare. From making medical services more affordable and accessible to putting a stop to discriminatory behaviour towards them, there are several steps that we as a society and polity need to take to ensure their wellbeing.
Furthermore, this study also highlights how the availability and awareness of basic healthcare such as easy access to abortion pills and health facilities can help in the betterment of the lives of these individuals. It will further help reduce the deaths due to poor healthcare. It might also result in the improvement of the mental well-being of female sex workers and eventually reduce the number of deaths by suicide.
Sex workers should not be discriminated against anywhere, let alone in a place like a hospital. Most female sex workers are battling through numerous mental and physical health conditions, and it is high time to address their difficulties and work towards making life better and dignified for them.