La santé reproductive des femmes travailleuses du sexe de l'Afrique de l'Ouest : survol des facteurs de risque, de la survenue, des issues et des intentions entourant les grossesses

L'objectif principal de cette thèse est de brosser un portrait de la santé reproductive des femmes travailleuses du sexe (FTSs) de l'Afrique de l'Ouest (Bénin et Mali) afin d'informer les décideurs et ainsi d'adapter les programmes qui assurent des services au sein de cette population vulnérable. Cette démarche vise à prévenir la mortalité maternelle en évitant les grossesses non désirées et en accompagnant et ciblant les femmes qui désirent des grossesses pendant la pratique du travail du sexe. Pour ce faire, trois objectifs spécifiques ont été définis. Premièrement, faire un survol des facteurs de risque associés aux grossesses lors de la pratique du travail du sexe. Deuxièmement, quantifier la survenue des grossesses et leur issue avant et pendant cette pratique du travail du sexe. Finalement, déterminer les intentions qui entourent les grossesses et l'association entre leur survenue et cette intention. Tout d'abord, notons que les facteurs de risque ont été identifiés à l'aide d'une régression de Poisson avec équation d'estimation généralisée et d'une sélection descendante des facteurs de risque. Les principaux facteurs associés aux grossesses et identifiés dans le cadre de cette thèse sont : le jeune âge des FTSs, pratiquer le travail du sexe depuis plus de deux ans et avoir un petit ami. Le devis transversal de cette analyse ne permet pas de tenir compte de la temporalité ni d'évaluer une association causale potentielle. La grande taille de l'échantillon et la représentativité de celui-ci permettent la transférabilité des résultats à la population générale des FTSs. De plus, la comparaison des issues de grossesses avant et après la pratique du travail du sexe a été faite à l'aide du khi carré de McNemar, et le calcul des taux d'incidence à l'aide d'un modèle linéaire généralisé et d'imputations multiples. L'évaluation de la survenue des grossesses a permis d'identifier que le taux d'incidence de grossesse était deux fois plus élevé avant la pratique du travail du sexe que pendant. Enfin, le taux d'avortement est beaucoup plus élevé pendant la pratique du travail du sexe. Le sujet très sensible des grossesses et l'illégalité des avortements entraînent nécessairement une sous-estimation de l'incidence des grossesses et du taux d'avortement. Le fait que des professionnelles de recherche formées aient questionné les femmes dans des cliniques consacrées aux FTSs a aidé à diminuer ces biais. Finalement, la distinction entre les grossesses survenues avant et pendant la pratique du travail du sexe a permis d'avoir une vision plus claire du taux d'incidence associé à ce travail, évitant ainsi des biais d'information. Enfin, des données longitudinales récoltées sur une période d'un an ont été utilisées pour mesurer l'association entre l'intention d'avoir une grossesse et la survenue d'une grossesse pendant la pratique du travail du sexe. L'intention d'avoir une grossesse a été évaluée au recrutement et à six mois à l'aide d'une mesure multidimensionnelle prospective développée et validée pour l'étude. La survenue de grossesse a été mesurée à l'aide d'un test d'urine et d'une question rétrospective à six et 12 mois. L'intention a été définie en trois catégories afin de tenir compte de l'ambivalence, et a été mesurée prospectivement. L'association a été mesurée à l'aide d'un modèle à risque proportionnel de Cox, et la mesure de l'intention a été validée à l'aide d'une analyse hiérarchique par grappe (clustering). L'inverse de probabilité de censure a aussi été utilisé afin de tenir compte des femmes perdues au suivi. Une femme sur six désire un enfant dans les six prochains mois, et ce, malgré la pratique du travail du sexe. Une sur quatre est ambivalente. Trois sur cinq ne veulent pas devenir enceintes. Selon l'intention, la survenue d'une grossesse augmente de façon proportionnelle. Les données sont autorapportées et donc sujettes à la désirabilité sociale, alors que les pertes au suivi ont diminué la capacité de détecter une association, bien qu'une tendance semble présente. En conclusion, malgré la pratique du travail du sexe, il n'est pas rare qu'une femme désire avoir un enfant. En dépit de cette réalité, le taux d'incidence des grossesses reste deux fois plus élevé avant la pratique du travail du sexe. Par contre, les avortements s'avèrent plus fréquents « pendant ». Les femmes qui tombent enceintes pendant la pratique du travail du sexe, sans regard à l'intention, semblent plus vulnérables.The main objective of this thesis was to gather information on the reproductive health of West African (Benin and Mali) female sex workers (FSWs). This knowledge will inform policymakers and help adapt the programs that provide services to this vulnerable population. This process aims at reducing maternal mortality by preventing unwanted pregnancies while identifying and supporting women who want a pregnancy during their sex work practice. To do so, three objectives were defined. Firstly, to provide an overview of the risk factors associated with pregnancy during sex work practice. Secondly, to quantify pregnancy occurrence and its outcomes before and during sex work practice. Finally, to identify the intentions surrounding the pregnancies and evaluate the association between pregnancy occurrence and intention. In the first place, the risk factors were identified using Poisson regression with Generalized Estimating Equations and robust variance. A backward selection was used. The principal risk factors associated with pregnancies and identified in this thesis were, younger age, practicing sex work for more than two years and having a boyfriend. The cross-sectional design did not allow to take the temporality into account and to evaluate the potential causal association. The results could be transferred to the FSWs' general population because of the large sample size and its representativeness. In the second place, a comparison between pregnancy outcomes occurring before and during sex work practice was carried out using McNemar chi-square. In addition, general linear models with multiple imputations were used to estimate and compare the incidence rate of pregnancy before and during sex work practice. The pregnancy incidence rate was twice higher before than during sex work practice. Moreover, the abortion rate was higher during sex work practice. The sensitivity surrounding pregnancy and the illegal aspect of abortions may lead to an underestimation of pregnancy occurrence and abortion rate. To minimise such biases, FSWs were recruited and interviewed at FSW-friendly clinics by trained research professionals. Finally, the distinction between pregnancies occurring before and during sex work practice allows a clearer evaluation of the incidence rate associated with sex work practice and prevents information biases. In the third place, the estimation of the association between pregnancy intention and pregnancy occurrence during sex work practice was evaluated using longitudinal data over a one-year period. The intention to become pregnant was assessed at baseline and at six months using a multidimensional measure specifically developed and validated for this study. Pregnancy occurrence was measured with a urine test and retrospective questions at six and twelve months. A Cox proportional hazard model was used to quantify the association and a cluster analysis to corroborate the multidimensional measure of pregnancy intention. Losses to follow-up were considered using the inverse of probability of censoring weights. One out of six women wanted a child in the next six months despite practicing sex work, one out of four was ambivalent and three out of five did not want to get pregnant. Pregnancy intention was measured prospectively and defined using three categories to include the ambivalence. The pregnancy occurrence increased proportionally to the intention level. Data were self-reported and could thus have entailed a social desirability bias. Losses to follow-up could have decreased the statistical power preventing the capability to detect a significant association even though a trend seemed to be present. In conclusion, it is not infrequent that women desire children although practicing sex work. Despite this reality, the pregnancy incidence rate was twice higher before sex work practice and abortions more frequent during sex work. Finally, women who face a pregnancy while practicing sex work seem more vulnerable

Twenty “must-read” research articles for primary care providers in Nunavik: scoping study and development of an information tool

While health needs in Nunavik are distinct, there is a scarcity of knowledge transfer intended for local primary care providers. We aimed to build an information tool in the form of a newsletter and a website to share with them a selection of relevant research articles. To identify such articles, a scoping study of Inuit health research published between 2012 and 2017 was conducted. Selection criteria were adapted from the framework of information mastery. After a database search yielding 2896 results, publications were screened for eligibility. Next, the 226 eligible articles were evaluated and scored for their relevance, their methods (including community participation), their local applicability and their clinical utility. The 20 highest-scored articles were selected for dissemination in a newsletter. They were summarised and presented in 6 thematic emails: Child Development, Infectious Diseases, Traditional and Modern Medicine, Metabolism, Nutrition and Contaminants, and Inuit Perspectives. The newsletter was sent to over 190 health workers and regional stakeholders in Nunavik and was also published online. We hope that this project will foster knowledge sharing and inter-sectorial collaboration between research, public health and clinical care. Trends in Inuit health research are discussed

Longitudinal study of pregnancy intention and its association with pregnancy occurrence among female sex workers in Benin and Mali

Plain Language Summary 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, a better understanding of their pregnancy intention and its influence on pregnancy occurrence could help prevent unwanted pregnancies and adverse effects of wanted pregnancies. We recruited 330 FSWs in Benin and 322 in Mali and we followed them for 12 months. We evaluated their pregnancy intention at recruitment and at 6-month follow-up. We assessed pregnancy occurrence with a pregnancy urine test and with a retrospective questionnaire asking on pregnancy occurrence at 6 and 12 months. With these data we estimated the association between intention and pregnancy. 407 FSWs were included in the first 6-month analysis and 284 at 12 months. Sixteen percent of the FSWs had a positive intention of having a pregnancy in the next 6 months in both the first 6-month and 12 months. One out of four were ambivalent and almost 60% had a negative intention. For 38.2% of the FSWs the intention changed between the two periods. Women with an ambivalent intention compared to those with positive intention, had 30% less pregnancies whereas for negative intention, women had 54% less pregnancies during the study follow-up. As for any woman, the level of pregnancy intention influences its occurrence. Moreover, nearly one out of six FSWs wants a baby despite working in the sex trade. Programmatically, early identification of these women could facilitate provision of quality antenatal and postnatal care