Characteristics, risk behaviors and factors associated with abortion among female entertainment workers in Cambodia

Abortion is a major public health concern in many parts of the world, particularly in developing countries where access to safe services is limited [1]. Globally, each year, an estimated 42 million abortions, both safe and unsafe, are performed [2]. More than half of abortions occur outside a legal system and are considered unsafe because they are mostly performed by unskilled and poorly trained providers or in settings that do not meet minimal medical standards. In developing countries, two in five abortions occur among women aged under 25 [1, 3, 4]. Globally unsafe abortions accounted for 13 % of maternal related death, in which most of the cases could be preventable by access to appropriate safe abortion services [5].

In Cambodia, 5 % of women aged 15–49 reported having had an abortion in the past five years and 43 % of the abortions took place outside health facilities [6]. Although abortion is legal in Cambodia before 12 weeks of pregnancy, there is a lack of trust in those available through the public health system because services are limited and facilities understaffed with compromised quality of care [7]. Among female entertainment workers, abortions and unintended pregnancies are highly prevalent, ranging from 25 % to 31 % among different types of entertainment workers [8‐12]. Studies in different parts of the world − Russia, Colombia, Hong Kong, and Thailand − reported that more than 50 % of the female sex workers reported having experienced at least one abortion in their life time. The risk of having an abortion has been reported to be associated with increased age, duration of sex work and number of partners [9, 13‐15].

In Cambodia, after the implementation of the law on women trafficking and exploitation in 2008 there was a crackdown on brothel-based sex establishments. In this context a new term, “female entertainment workers (EWs)”, began to be used to refer to both direct female sex workers (those based in brothels) and indirect female sex workers, (those whose primary job was serving beer in a beer garden, or providing escort services at karaoke lounges). Because of the law, sex workers in Cambodia have become hidden and shifted away from brothels toward other entertainment jobs such as beer promotion, beer garden waitressing, and karaoke hostessing. Currently, the EW label is used to define women who exchange sexual services for money or goods as income-generation on top of entertainment job [12, 16]. According to the latest national Behavioral Surveillance Survey (BSS) 2010, about 85 % of EWs had reported commercial sexual activities, and more than 79 % of them used to work in a brothel before moving to work in their current type of entertainment job [12].

Traditionally, HIV prevention efforts have focused on consistent condom use as dual protection for HIV, sexually transmitted infections (STIs) and unwanted pregnancies. In Cambodia, though 90 % of EWs reported high consistent condom usage with clients, there was lower and less (<50 %) consistent condom use reported with their “sweethearts”, defined as the partner from a non-commercial, non-marital sexual relationship that possesses a certain degree of affection and trust [11]. Moreover, a relatively high number of EWs reported sexual encounters with the latter. This reflects a high risk of unwanted pregnancies and consequently a high abortion rate among these women [11, 17].

These reproductive health (RH) issues (i.e. infrequent use of contraceptives, unintended pregnancy, and abortion) among EWs pose an additional public health concern for HIV programs. To date, this critical linkage between HIV and RH services has been much discussed and prioritised in terms of global policy [18, 19] but still remains weak in terms of country-level implementation, coordination, monitoring, evaluation, and resource allocation [20, 21] especially among those most at risk. For example, issues of unintended pregnancy, contraceptives and access to safe abortion services among EWs have not been integrated well into HIV prevention and treatment programs and/or effectively operated in most developing countries, including Cambodia [10, 22]. In 2009, recognizing that EWs are exposed to multiple risk behaviors and overlapping risk activities and require contraceptive services and access to safe abortion, The National Center for HIV/AIDS, Dermatology and STIs (NCHADS) in collaboration with non-governmental organizations (NGOs) and funding partners revised the standard operating procedure (SOP) for continuum of prevention to care and treatment for most of the at risk population including EWs to include linkage and integration to RH with the aim of maximizing the efficiency of service delivery [16]. Since then, that SOP has been implemented with the focus on the integration of RH services including provision of contraceptives and access to safe abortion services, STI screening and treatment, and referral services (i.e. family planning services and HIV voluntary counselling and testing) [16, 23]. Yet there has been little research on RH characteristics and socio-behavioral factors related to abortion among EWs except a study describing the contraceptive needs of brothel-based sex workers [24]. Much research has been focused on HIV/STI epidemiology and related socio-behavioral determinants [11, 25, 26] but not much on RH including abortion of high risk women. This leaves a major gap in understanding high risk women’s RH needs in addition to what is provided by HIV programs since the implementation of the integration of RH in the HIV prevention and care guidelines among EWs. Therefore, in this paper, we examine socio-behavioral characteristics, and RH practices associated with abortion among Cambodian EWs.

Our findings demonstrate that three quarters of the entertainment workers in our survey in Cambodia’s three most populous provinces were young and sexually active with a high proportion reporting history of recent abortion. In particular, the highest risk of having an abortion was found among women aged 25–29 years, and those currently living with spouses or cohabitated partners. The longer duration work as an EW clearly puts women at higher risk of unprotected sex resulting in higher reports of abortion. Finally, the risk of having an abortion was found to be linked to a specific type of entertainment job (i.e. working in karaoke establishments). This provides RH services a focus of whom among EWs to prioritize.

The study finding that not all EWs are sexually active, the exceptions being the masseuses, beer promoters and karaoke hostesses also helps provide programs focus. Given Cambodia’s recent budget constraints, this provides guidance on which categories of EWs contain those most sexually active and avoids targeting the whole EW population. However, non-sexually active women should be provided with behavioral change communication messages about HIV and RH before they become at risk of HIV infection and RH issues.

Our findings reveal nearly one third of the EWs experienced at least one abortion while working as EWs. This high rate of recent abortion among these women suggests that condom use alone as the dual protection against HIV and pregnancy is not effective in preventing unintended pregnancies, especially with non-paid partners (i.e. sweethearts). Non-barrier methods should be introduced given the low condom use and low use of other contraceptive methods. When compared with reports from women of reproductive age in the general population, the EWs are experiencing very high rates of abortions, especially those aged 25–29. Interestingly, data from Laos and Russia shows the risk of abortion among EWs increased with age [9, 24]. Our further analysis found that more women aged 25 years and older reported a having sweethearts than younger women, increasing their likelihood of an unintended pregnancy because of the low condom and contraceptive use with such partners. Therefore, integrated interventions should be focused on RH referral services beyond always condom use to contraceptive and safe abortion services, as was recommended in the HIV and RH integrated SOP.

EW women who reported living with spouses or cohabitated partners also had an increased risk of abortion. Anecdotal evidence suggests that many sweethearts of EWs are previous clients [16, 29]. Over time, their regular relationship had become intimate and transformed a client into a regular client and then sweethearts and eventually, to some extent, many eventually become EWs’ cohabitating partner or spouse. This relationship pattern represents a challenge for an HIV prevention program and suggests an urgent need for practical, feasible and realistic RH services, which could be integrated as part of the HIV integrated program. As shown in the results, consistent condom use with a sweetheart was as low as 35 % and this was confirmed in other reports [11, 12, 24]. Over the years, consistent condom use among sex workers or EWs with their sweethearts has never exceeded 50 % although repeated efforts have been made to address the issue [11]. Condom use is seen to reduce intimacy and reflects a lack of trust. Working in entertainment jobs while maintaining an ongoing sexual partnership seems to put these women at the greatest risk of abortion, as negotiating an effective and consistent approach to family planning may be particularly challenging within the established partnership.

While many women working in entertainment establishments are exposed to health education about condom use for HIV/STI prevention through mass media outreach and peer education programs, there is little discussion of broader RH issues apart from referral for STI screening and treatment. Our findings suggest that in addition to condom promotion, specific RH needs including access to safe abortion services, avoiding unintended pregnancy, and choice of contraceptives, are of critical importance for women working in entertainment jobs and establishments [22]. In the past, abortions have been widely used by EWs voluntarily to deal with unintended pregnancies although it is perceived as both risky and costly [10]. As shown in our findings, contraceptive methods used were still unacceptably low, including condom use with intimate partners. This suggests that intimacy, trust, love, social support and safer financial security from their cohabitated partner or sweethearts may prohibit use of contraception posing further hurdles for the HIV integrated services.

Recognizing that EW’s practice multiple risk behaviors and lack of access to contraceptive and safe abortion, the SOP for HIV prevention to care with an integration to RH has been implemented [16]. However, no research has been conducted to assess the extent to which this integrated SOP implementation is effective and feasible. Furthermore, anecdotal evidence suggests that although the HIV and RH integrated SOP has been implemented, erratic activities have been documented across provinces due to a number of reasons, such as lack of motivation for local HIV staff, referrals issues to RH clinics, and underfunding (about 90 % of the HIV and RH activities have been supported through external funding). This was also supported by the findings from other settings, where the delivery of HIV and RH programs always face challenges in terms of policy priority, reporting, monitoring and evaluation system coordination between stakeholders in HIV and RH programs, and the underfunded RH [21, 30]. These anecdotal reports of program difficulties along with the clear lack of utilization of broader contraceptive services reported by EWs in our survey, suggests Cambodia’s integrated HIV/RH program has a long way to go to reaching those most at need.

The link between duration of work in an entertainment job and increased risk of abortion suggests a cumulative exposure to health challenges, to HIV/STI and RH issues, and especially unsafe abortions. This finding was confirmed in many studies in different settings [9, 24]. An example is work as a karaoke hostess that was associated with a higher risk of abortion than work in other entertainment categories. While one third of the women working as karaoke hostess report an abortion during their time in entertainment work, only about 5 % of Cambodian women in the general population report an abortion in past 5 years [6]. Therefore, the elevated percent of women working in karaoke who have an abortion may reflect the nature of this working environment where women have to entertain clients with songs, escort services and alcohol, and ultimately the negotiated sexual services. Such commercials sexual encounters while also working as a “performer” may prove more challenging for women. We also found that karaoke hostesses earned twice as much as other women (data not shown) also suggesting selling sex or these women may operate on different terms than for other women working in entertainment Finally, another study found karaoke hostesses report more clients and more paid sex compared to beer promoters [31] again pointing to their elevated risks of high risk sexual exposures.

The study has faced a number of limitations. The first concern relates to the social desirability bias [32] embedded in asking about personal and sensitive information, including past sexual practices, condom use and abortion in a face to face interview. EWs who have been frequently exposed to outreach and peer education programs may intend to give positive and desirable responses to interviewers; however, this type of bias may be reduced to a minimum through the use of the national validated questionnaire and training of female interviewers in dealing with such sensitive and personal information. Additionally, the fieldwork was undertaken under close supervision to ensure the privacy, confidentiality and anonymity of the participants. The second concern might be that the RH terminology might not have been clear in the questionnaire since it was originally designed to collect information about the HIV prevention and care program. However, concern about these limitations is reduced because we found that our findings were consistently in line with the results of the past studies [9, 11, 24].

This study highlights a relatively high proportion of EWs reporting abortion. While the vulnerability of the young women who work in this industry for HIV/STI acquisition has been clearly established, their broader sexual and RH needs have gone largely unrecognized and have not been prioritized. The HIV and RH integrated program initiatives were introduced in 2009 by the HIV prevention community in Cambodia; however, challenges for these women of multiple risks from professional as well as personal partners are profound. For these young women the context of high risk sex intertwined with development of intimate partnerships points to the need for multipurpose technologies that combine pregnancy and HIV/STI prevention in a single method. While such methods are in development, there is an urgent need for practical programmatic approaches including expanded contraceptive and abortion care services to help to improve the RH of these young women.