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Despite most FSW being mothers, little is known about their childbirth care or birth outcomes. To our knowledge, this is the first multicountry study to describe adverse birth outcomes among FSW in LMIC.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This cross-sectional study used a convenience sample of 853 FSW from eight cities in the Democratic Republic of the Congo (DRC), Kenya, and Nigeria to examine antenatal care (ANC) utilization, substance use during pregnancy, skilled birth attendance, and birth outcomes (stillbirth, perinatal mortality, and low birth weight). Self-reported outcomes for the five years preceding data collection were compared descriptively with national survey data for urban women to provide context.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Maternal health service utilization and birth outcomes varied widely by country. FSW participants in Kenya reported high ANC utilization (95.6%) and facility delivery (97.0%), comparable to urban women. ANC utilization and facility delivery were lower among FSW participants in the DRC (ANC: 49.0%; facility delivery: 68.0%) and Nigeria (ANC: 37.5%; facility delivery: 26.1%) compared to urban women. Cost and stigma were the main barriers. Alcohol use during pregnancy was common in all countries. Stillbirth rates among participating FSW were very high (113 per 1000 births in the DRC [95% CI 85\u2013146], 49 in Kenya [95% CI 30\u201375], and 85 in Nigeria [95% CI 63\u2013111]), as was perinatal mortality. Low birth weight prevalence was high in the two countries with sufficient birthweight data (DRC: 17.1%; Kenya: 9.7%).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>In this study sample, adverse birth outcomes\u2014high stillbirth and perinatal mortality and low birth weight\u2014may reflect the combined effects of limited access to quality maternal health services (MHS) and broader social, economic and health vulnerabilities documented among FSW populations. Kenya\u2019s subsidized maternal healthcare system may contribute to higher MHS utilization and better birth outcomes observed in Kenya. Improving equity in maternal and newborn health for FSW requires increasing access to quality MHS and addressing underlying social determinants of health. FSW should be recognized as a high-risk population requiring targeted maternal health interventions.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s12889-026-28825-9","type":"journal-article","created":{"date-parts":[[2026,8,12]],"date-time":"2026-08-12T05:13:41Z","timestamp":1786511621000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Maternal health service utilization and birth outcomes among female sex workers in the Democratic Republic of the Congo, Kenya, and Nigeria: results from a cross-sectional survey"],"prefix":"10.1186","volume":"26","author":[{"ORCID":"https:\/\/orcid.org\/0009-0000-5686-8915","authenticated-orcid":false,"given":"Isabella","family":"Danel","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Regan","family":"Moss","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brian","family":"Willis","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Swarna D. 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All participants were adults aged 18 years or older and therefore able to provide their own informed consent. All participants gave their written informed consent, which was formally recorded and witnessed by the lead researcher (BW). Our ethical guidelines, standards, and disclosures meet or exceed those required under the Declaration of Helsinki.","order":1,"name":"Ethics","label":"Ethics approval and consent to participate","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Not applicable.","order":2,"name":"Ethics","label":"Consent for publication","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"RM, KB received compensation from Global Health Promise to conduct analyses and contribute to the writing of the manuscript. HT is a Global Health Promise Board Member. ID, BW, SW, PE, GK, EP, WMK have no competing interests.","order":3,"name":"Ethics","label":"Competing interests","group":{"name":"EthicsHeading","label":"Declarations"}}],"article-number":"3053"}}