Global epidemiology of abortion among female sex workers: a systematic review, meta-analysis, and meta-regression

Purpose: Despite the evidence of a high rate of unintended pregnancy, there remains limited information about the prevalence and experiences of abortion among female sex workers (FSWs). In response, we aimed to summarize the available evidence on abortion among FSWs. Methods: We searched Medline, Embase, PsycINFO, CINAHL, Scopus, and Web of Science from inception to January 29, 2023. We pooled data from the included studies using random-effects meta-analyses. We also grouped countries for the legality of elective abortion stratified by the United Nations database on abortion laws and policies. Results: We identified 60 eligible studies from 2031 potentially eligible records. The pooled lifetime prevalence of at least one and multiple induced abortions was 37.7% (95% confidence interval, 31.8–43.7) and 21.7% (14.9–29.2), respectively. Among FSWs recruited in countries where elective abortion is illegal, at least one induced abortion prevalence was 35.1% (28.1–42.4), and multiple induced abortion prevalence was 23.1% (12.4–35.9). In countries where elective abortion is legal, at least one induced abortion prevalence was 44.6% (34.8–54.6), and multiple induced abortion prevalence was 19.9% (11.9–29.3). Among FSWs experiencing abortion, self-managed abortion prevalence was estimated at 32.8% (23.6–42.7) overall, 42.8% (37.2–48.5) for countries where elective abortion is illegal, and 15.6% (3.9–32.7) for countries that legally allow elective abortion. Conclusions: Induced abortion is prevalent among FSWs, highlighting the need for interventions to increase access to effective contraception and safe abortion care. While induced abortion prevalence did not significantly differ across the legal grounds for abortion, self-managed abortion prevalence was higher in countries where elective abortion was illegal, highlighting the urgent need for accessible abortion services for FSWs in criminalized settings. Moving forward necessitates implementing and evaluating culturally acceptable models of safe abortion and post-abortion care for FSWs to increase access to the full spectrum of sexual and reproductive health services.