Macias-Konstantopoulos, W.L., Perttu, E., Weerasinghe, S., Dlamini, D., Willis, B. (2024). Causes of preventable death among children of female sex worker mothers in low- and middle-income countries: A community knowledge approach investigation. J Glob Health, 14, 04052.
Female sex workers (FSW) in low- and middle-income countries (LMIC) face significant health, social, and economic challenges, which also impact their children (CFSW). Despite existing child mortality data, specific causes of death among CFSW are not well-documented, hindering effective public health responses. Using the Community Knowledge Approach (CKA), a survey conducted from January to October 2019 across 24 cities in eight LMICs involved 1,280 FSW participants. Detailed reports from these participants revealed 668 child deaths, with 589 included in the analysis. Leading causes of mortality were nutritional deficiencies (20.7%), accidents (20.0%), overdoses (19.4%), communicable diseases (18.5%), and homicides (9.8%), along with neonatal conditions, respiratory illnesses, and suicides. These deaths are largely preventable with better protections. Governments, intergovernmental organizations, NGOs, and funders can implement targeted policies and programs to protect CFSW and support vulnerable FSW who are pregnant or raising children. Further research is needed to identify effective child welfare safeguards for CFSW.
Data collection took place from January 16, 2019, to October 1, 2019, across 24 cities in the eight study LMICs, using an open-ended, semi-structured questionnaire previously utilized in a similar single LMIC study. Local interpreters, approved by partners and trained on study protocols, ensured accurate forward and backward translation under the direct supervision of the lead investigator. Participants were asked to provide information about any deaths of FSW and CFSW that occurred since January 2014. Data collected on deceased CFSW included sex, age at death, year of death, and cause of death. Extensive handwritten notes, including verbatim quotes and contextual details, were recorded. After each group session, the research team reviewed all reported deaths to identify potential duplicates, recording only the first instance if two deaths matched on two reported details. Data were entered into an Excel database and reviewed by at least two research members for accuracy, completeness, and duplication. Child deaths were coded by three team members and classified by cause of death according to WHO global classifications of noncommunicable, communicable, and injury-related leading causes of death. Neonatal deaths, defined as occurring within the first 28 days of life, were attributed to birth asphyxia and trauma, neonatal sepsis and infections, and preterm birth complications. Age groupings followed WHO reporting practices, with 24 years as the maximum age for inclusion, representing brain maturation. Although ages 18 and older fall outside the legal definition of a child, the study included data for 18–24-year-olds to reflect the socioeconomic circumstances, health-related social risks, and adverse childhood experiences of CFSW. Deaths across all years were combined and organised by country, age group, and cause of death. Cause of death discrepancies were resolved through discussion and review of the original field notes, in conjunction with the lead investigator, until consensus was reached. Descriptive summaries report the total number of child deaths by sex, age group, country, and cause of death.
The study's strengths include its cost-effectiveness, resource efficiency, and relatively quick implementation, making it a validated method for identifying causes of death among communities of adult women and children in low- and middle-income countries (LMICs). It leverages community knowledge to accurately report deaths, which is particularly useful in contexts where household surveys or official records may be challenging to obtain. However, the study has limitations, such as the potential for selection bias, time constraints that may limit the completeness of participant memories, and the inherent differences between study locations that affect generalizability. Additionally, without accurate size estimates of the total population of children of female sex workers (CFSW) in any given country, mortality rates cannot be estimated, limiting the ability to draw conclusions about differences in causes of death across countries.