This article originally appeared on Tonic.
Sreyleap* had been a sex worker for two years when she first realized she was pregnant. She had moved from rural Cambodia to the capital, Phnom Penh, when she was just ten to work as a babysitter, and then at 16, turned to the "entertainment industry"—the broad-sweeping term used in Cambodia for the karaoke bars, beer gardens and nightclubs where female sex workers often ply their trade.
"I didn't know who the child's father was because I had slept with many partners and I sometimes did not use condoms," says Sreyleap, who is now 24. Newly married at the time, she decided to seek an abortion, visiting a medical clinic where she was given "a kind of medicine."
Although she was unsure what doctors had prescribed, Sreyleap trusted their advice and took it.
"My body hurt all over for around a week and I felt weak afterwards," she says. Despite enduring a physically and emotionally trying experience, Sreyleap was one of the lucky ones.
A study released late last year found that while an astounding 30 percent of the total number of maternal deaths in Cambodia are caused by abortions, the number gets bumped to 40 percent when you look exclusively at sex workers.
The report, by Portland-based non-profit Global Health Promise, is the first to investigate the causes of maternal deaths among sex workers anywhere in the world. In interviews with 271 women across four major cities in Cambodia, researchers gathered information on 194 deaths.
Of this small albeit revealing subset of women studied, a quarter had reportedly died from maternal health complications. Abortion was the most common cause of maternal deaths, followed by HIV infection. Global Health Promise director Brian Willis, who received a Fulbright grant to pursue the research, says the study did not reveal why abortions killed so many women but adds that "clearly this issue warrants additional research."
Cambodia's government legalized abortion in 1997 in an effort to help bring down the maternal mortality ratio, which reached 1,000 deaths per 100,000 live births in 1990 after devastation caused by the Khmer Rouge and decades of civil war left health services in the country deeply strained.
Supported by international donors and non-governmental organizations, the country has succeeded in doing just that: The World Health Organization estimates that just 161 women died per 100,000 live births in 2015.
However, this number is still high compared with the country's more developed neighbors, and access to abortion—available on request for the first 12 weeks, and then under specific circumstances later in the pregnancy—presents a particular challenge for many Cambodian women. "Obstacles include difficulty finding providers willing to perform abortion, substandard conditions in health facilities, lack of awareness of the legal status of abortion and fear of stigmatization for terminating a pregnancy," according to the Guttmacher Institute.
Health workers back up the claim that many women in Cambodia are unaware of the legal status of abortions—the sex workers interviewed for this piece also believed abortion is illegal—and this misconception, combined with the stigma surrounding their profession, often sees them to turn to unqualified medics performing cheap, back-alley procedures. One traditional technique used regularly is a "deep massage" of the womb, known to cause fatal hemorrhages.
"Because abortion is sensitive and the women don't want to disclose their pregnancy, sex workers, as the most vulnerable group, tend to go somewhere where they can hide their identity, where it's cheap. They often go to an unqualified provider," Var Chivorn, executive director of the Reproductive Health Association of Cambodia, tells the Phnom Penh Post newspaper.
Backing up this assertion, the Guttmacher Institute found that just 14 percent of abortions were performed in public hospitals in 2010, while 38 percent took place in private homes (the latter is immensely more dangerous). There's also some evidence that sex workers may be using abortion services more often than the general female population.
Younorng* is unsure how many times she has had an abortion during her 15 years as a sex worker in Cambodia's capital, Phnom Penh. "Maybe ten times already," she says. "After falling pregnant with my husband five times, and the rest with customers."
Already a mother to five children aged between eight and 28, Younorng, who is now in her 40s and earns between $10 and $20 per client, says she felt she had few options when faced with an unwanted pregnancy. "I couldn't keep the babies, because I couldn't afford them.''
Sophoan Chan, advocacy and campaign coordinator for Women's Network for Unity, a Cambodian organization that advocates on behalf of sex workers, is currently undertaking a research project into the health of women working in the sector. She says the number of abortions Younorng has experienced is higher than most, but of the 70 women she has interviewed to date, "85 percent of them experienced at least one abortion."
"In the beginning when I asked, they said, 'No, I have no experience with abortions.' But when we [probed] deeply, they said, 'Yes, I have experienced it,'" she says. "They are really embarrassed [to talk] about it."
Chan adds that the project is also looking at contraceptive methods employed by female sex workers. "There are around 20 percent of women who use the contraceptive pill and the rest, they use condoms," she says.
However, she says that the use of condoms is sporadic among female sex workers due to their clients' resistance to using them. While both Younorng and Sreyleap regularly carry and attempt to use condoms, they say that clients often bristle at the request.
And for Sreyleap, whose husband is a poorly paid laborer, the choice between taking home extra cash to support her six-year-old daughter and putting her body at risk is no choice at all. "I don't use a condom when I am drunk or when a customer doesn't want to use it," she says. "I'm afraid of getting a virus as well [as getting pregnant], but I don't know what else to do.''
Additional reporting by Hay Pisey
*Sources preferred to use only their first names.