Emergency contraception among female sex workers: systematic review and meta-analysis

Introduction: Female sex workers (FSW) experience an elevated risk of unintended pregnancy due to condom failure, covert condom removal (stealthing) and sexual violence. Emergency contraception (EC) can prevent pregnancy after such exposures, but evidence on EC knowledge and use in this population has not been comprehensively synthesised. 
Objectives: To summarise EC knowledge and use among FSWs and estimate the pooled lifetime EC use 
Methods: A systematic review of peer-reviewed studies published from 1 January 2000 to 8 February 2025, was conducted using Lens.org, Dimensions, PubMed and Google Scholar. Study quality was appraised using the Joanna Briggs Institute checklist for prevalence studies. Lifetime EC use was pooled using a random-effects model, with subgroup analyses by region and sampling design. 
Results: Twenty-four studies were included in the systematic literature review, whereas eight studies (11 samples; n=5670; 1166 ever-users) were eligible for meta-analysis. Pooled lifetime EC use was 21.0% (95% CI: 12.0%, 35.0%), with very high heterogeneity (I²=97.8%). Pooled estimates were similar in Asia (18.0%) and sub-Saharan Africa (22.0%). Studies using respondent-driven sampling yielded a lower pooled prevalence (15.0%; 95% CI: 7.0%, 29.0%) compared to other sampling approaches (43.0%; 95% CI: 28.0%, 59.0%). Across settings, knowledge was uneven and EC use after condom failure or rape was frequently missed; barriers included misconceptions, fear of side effects, cost, stigma and limited access to suitable services. 
Conclusions & Recommendations: EC use among FSWs is modest and highly context dependent. Programmes should prioritise timely, low-barrier and stigma-free EC access (including advance provision) and integrate EC within post-exposure and broader sexual and reproductive health care.