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Barriers and unmet need for contraception services and related reproductive health outcomes among female sex workers especially those with multiple and intersecting vulnerabilities and adolescent girls surviving in sex workers’ settings in Uganda

Unmet contraception need has historically had a detrimental implication on women’s reproductive health. Sub-Saharan Africa has one of the highest unmet contraceptive needs in the world, and Uganda has one of the region’s youngest populations. In the country, several barriers underpin poor access to contraceptives, which destructively affect users’ reproductive health and rights. The overall unmet need for Family Planning in Uganda is 30.5% which is way below the target of 10% by 2022 the country committed to accelerating universal access to family planning as a tandem to reducing the unmet need. Uganda continues to present undesirable fertility rates (5.4 births per woman, and 6.3 births per minoritized woman, such as women living with disability) and maternal mortality ratios of (336 maternal deaths per 100,000 live births). This is principally attributed to the contraceptive non-use. Studies on contraceptive non-use across the regions in Uganda recognize and attribute this to the following factors: educational level, age, wealth status, fear of side effects, residence, low quality of contraceptive services, alcohol intake, income, sex, and age at first sex, to mention but a few.
Following the virtual stakeholder advocacy dialogue on “Addressing barriers underneath, the continuous complexity cycle of contraceptive inaccessibility and utilization among the minoritized women and AGYW in Uganda”, from 20/09/ 2021 – 27/09/2021 AWAC conducted an assessment of the contraceptive needs and barriers with related reproductive health outcomes in Mbarara, Kikagate Isingiro, Malaba-Tororo, Gulu, Mbale, Gulu, Kitgum, Pader, Amuria, Kaberamaido, Dimu and Lambu -Masaka, Wakiso, Kampala, Kasesnsero -Rakai, and Mbale districts.
These activities come on the heels of AWAC programmatic shift to the integration of the intersectionality lens as highlighted in the AWAC new Strategic plan and SWoFAA 2020/21-2024/25. The activities will equally inform fine-tuning of UAF proposal and advocacy on unmet need for contraception among female sex workers in Uganda

Background
Female sex workers, Adolescent girls surviving in sex work settings especially those with multiple and intersecting vulnerabilities in Uganda and elsewhere in the world bear face disproportionate share of contraception services access barriers, unintended pregnancies and related adverse reproductive health outcomes. However, little evidence exists on the barriers and unmet need for contraception services and related reproductive health outcomes among female sex workers including those with multiple and intersecting vulnerabilities and adolescent girls surviving in sex work settings.

Aim
The assessment therefore aimed at examining the barriers and unmet need for contraception services and related reproductive health outcomes among female sex workers including those with multiple and intersecting vulnerabilities in Uganda.

Objectives
To examine level of the unmet need for contraception services among female sex workers especially those with multiple and intersecting vulnerabilities and adolescent girls surving in sex workers’ settings in Uganda
To identify the barriers to contraception services among female sex workers especially those with multiple and intersecting vulnerabilities and adolescent girls surviving in sex work settings in Uganda
To identify the adverse reproductive health outcomes accruing from the barriers and unmet need for family planning among female sex workers especially those with multiple and intersecting vulnerabilities and adolescent girls surviving in sex work settings in Uganda.

Assessment scope
We explored their pregnancy history including previous experience of unplanned pregnancy, the outcomes of the pregnancy, whether they have ever been in situation that forced them to have the pregnancy terminated, whether they were using any non-barrier method of contraception, and those who were using duo contraception

Methodology
A total of 220 eligible respondents sampled The assessment focused on those who had exchanged sexual services for money or valuable material goods in the past 60 days; were not currently pregnant or trying to get pregnant
District coordinators, peers and CHLEG networks, GACs were used as entry points that facilitated respondent driven/ snowball sampling to source assessment respondents. Participants from the respective districts were contacted either via phone or social media platforms (WhatsApp or Facebook) and asked to talk to their colleagues about the assessment, and share phone contacts of potential volunteers for the assessment. The main inclusion criteria were that the potential respondent had to be a resident of that district belonging to any of the following categories; - FSWs, FSWs with disabilities, FSWs using drugs, Refugee sex workers, and Adolescents surving in sex work settings
Following the interviews, respondents were given a phone contact of the interviewer and asked to share their experience in relation to assessment and its importance with at least one peer, as well as request for permission to share with the interviewer. The interviewer would then call any new contact and request her to participate in the assessment, from social media platforms.
An interview guide was developed and reproduced into several soft copies which were used during an interview to collect the needed data. Interviewers read the questions to the respondents, recorded the answers in their note books, and typed them using MS Word program on their computers.
Respondents’ data was extracted from the interviewers’ note book, typed and organized based on respective themes and categories in MS word and then transferred in MS Excel for analysis. Data was analyzed and presented according to themes and patterns of meaning across data sets.

Results
The findings indicated that 65% (143) of the 220 of the eligible clients had an unplanned pregnancy before. 38% had been in a situation that forced them to have the pregnancy terminated. 20% (44) of the total respondents had disability, 15% (33) were refugees, 60% (132) were using drugs, 25% (55) were adolescent girls surviving in sex workers’ settings. 26% (57) of the respondents were living with HIV 75% (165)of FSWs with disabilities were experiencing unmet need for FP, 68% (149) of the FSWs Drug users reported having current unmet need for Family planning; 53% (117) of FSWs living with HIV had unmet need for contraception, 60% of the Refugees FSWs were experiencing unmet need for family planning, while 65% of adolescent girls surviving in sex work settings reported having unmet need for family planning.

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