Unintended Pregnancy and Pregnancy Awareness among Female Sex Workers in Sri Lanka: A Community-Based Cross-Sectional Study.

Unintended pregnancy is a key marker of unmet sexual and reproductive health needs, yet quantitative evidence among female sex workers (FSWs) in Sri Lanka is scarce. We conducted a cross-sectional respondent-driven sampling survey among 551 FSWs aged 18-49 years in Colombo from March to June 2025. Using Gile's successive sampling estimator, we generated respondent-driven sampling-weighted prevalence estimates and described pregnancy awareness, testing, and mitigating actions taken following pregnancy recognition among this sample. We conducted multivariate logistic regressions to identify women-level correlates of ever unintended pregnancy. Pregnancy-level prevalence was contextualized against six Sri Lankan non-sex worker studies using meta-analysis. Most participants had ever been pregnant (88.5 percent). Among ever-pregnant women, 51.1 percent reported at least one unintended pregnancy, and 39.8 percent of 1,225 lifetime pregnancies were unintended. Around two-thirds of FSWs recognized their most recent pregnancy by four weeks' gestation, but routine pregnancy testing was uncommon (11.3 percent), 44.8 percent reported no preventive measure at their most recent unintended pregnancy, and the pregnancy-accounting cascade indicated important downstream consequences. The risk of unintended pregnancy was found to be more clustered among women initiating paid sex before age 19 and those with higher parity. Pregnancy-level unintended pregnancy exceeded pooled non-sex worker estimates by about 11-13 percentage points. Taken together, the findings point to missed opportunities at both the pregnancy recognition and preventive response stages of the pathway. These findings support targeted sexual and reproductive health programs for FSWs in Colombo that prioritize routine and outreach-based pregnancy testing, rapid access to acceptable contraceptive options, and focused support for women entering sex work early, those with repeated pregnancies, and those who took no preventive measures at unintended conception.