People migrate voluntarily for a variety of reasons—largely to join other family members or to find better living conditions and jobs (89). Others, however, see little choice but to flee conditions of poverty and deprivation that may threaten their very existence. People may be uprooted by natural disasters and environmental degradation (82, 149, 330), while others are pushed out by economic development projects such as dams and by government facilities from weapons testing areas to wildlife sanctuaries (58, 191, 238). In contrast, by definition, most refugees and internally displaced persons are fleeing war, communal violence, and other political and social upheaval (131, 314).

In 1951 the Geneva Convention defined a refugee as "any person who, owing to a well founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of his nationality and is unable or owing to fear is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence, is unable, or having such fear is unwilling, to return to it" (105, 196, 295, 320).

In 1967 the Protocol Relating to the Status of Refugees incorporated post-1951 refugees and explicitly included those from outside Europe in the definition. Some countries, however, still define refugees by the geographic limitations of the 1951 definition and do not recognize non-European refugees (255). In 1969 a convention of the Organization of African Unity, applying only to African countries that have signed it, extended the definition to include as reason for refugee status "external aggression, occupation, foreign domination or events seriously disturbing public order in either part or whole" of a country (255, 335). The Cartegena Declaration of 1984 broadened the scope of the refugee declaration in a similar manner for countries in Latin America (255).

While there are no comparable official definitions of an internally displaced person (314), one definition often used is: "persons or groups of persons who have been forced to flee, or leave, their homes or places of habitual residence as a result of armed conflict, internal strife, and habitual violations of human rights, as well as natural or man-made disasters involving one or more of these elements, and who have not crossed an internationally recognized state border" (73, 93).

In contrast, refugees usually have not entered their country of asylum through conventional channels. For this reason their legal status is often unclear, although usually the United Nations High Commissioner for Refugees (UNHCR) takes responsibility for them. Furthermore, there may be political reasons that states do not grant an individual or group refugee status. Turkey, for example, recognizes Bosnians as refugees but not Iranians (255). Internally displaced persons are often in an even more precarious legal position because no body of law protects them. They may be subject to roundups, forced moves, and arrest (72, 93).

The DHS program consists of national sample surveys in more than 50 developing countries, funded chiefly by the US Agency for International Development (USAID) and conducted with technical assistance from Macro International, Inc. These surveys provide comparable information on fertility, family planning, and maternal and child health for women of reproductive age and sometimes their husbands or for men in general. In some countries (Egypt, Indonesia, and Pakistan, among those studied here), the sample of women was limited to ever-married women.

The surveys involve a common set of questions, and then individual countries can add their own questions. In this report data from 22 countries are analyzed. For some topics, certain countries did not ask the relevant questions; in such cases the results refer to fewer than the full 22 countries.

Rural-to-Urban Migrants Compared with Urban Nonmigrants
DHS data can distinguish between rural-to-urban migrants and urban nonmigrants. For most countries included for analysis in this report, these two groups were distinguished, among all urban residents, by the most recent prior place of residence—whether an urban area (city or town) or a rural area. Women whose last previous residence was in a rural area were classified as rural-to-urban migrants. Women who said their last previous place of residence was a "city," or "town," or who said "always lived here" were classified as urban nonmigrants. (Some of these women may have been born in a rural area but moved first to a different urban area than their current one.) The DHS also asked length of time at current residence, enabling study of differences among migrants according to length of residence in the city.

Surveys of Bolivia, Indonesia, and Zimbabwe asked about childhood place of residence but not about most recent place of residence. Different definitions of migrant and nonmigrant have been used in other DHS-based research (201, 211).

No international consensus currently exists about what is "urban" or "rural," and definitions differ widely among countries (211). Such variations must be kept in mind when using DHS and other data to compare migrant characteristics among countries. They do not affect comparisons within each country.

Using DHS Data
DHS data on migrants remain little used, and few published analyses of DHS data consider migrants as a separate group. This report presents only a small part of what could be done to analyze their situation. For example, analysis could be done not only to compare rural-to-urban migrants and urban nonmigrants, as this report does, but also to study rural nonmigrants and rural-to-rural and urban-to-urban migrants. In some regions, such as sub-Saharan Africa and India, rural-to-rural migration is still the dominant form of movement among women (46). Urban-to-urban migration will increase as levels of urbanization rise.

In this report only cross-tabulations of data are presented. No standardization for age, marital status, or other factors has been attempted, nor have multivariate analyses been done. Small differences are not necessarily statistically significant. The data presented here represent a first look at differences between migrants and nonmigrants.

As others analyze DHS data further, much more can be learned about migrants in developing countries. In particular, recent DHS in countries where contraceptive prevalence is widespread have collected information by using a monthly calendar approach, in which respondents report the timing of various reproductive events (92). While analyzing such data is difficult, it remains potentially valuable for understanding relationships between events related to migration and contraceptive use, fertility, and other reproductive health matters (41). Data sets from DHS recently have become available free of charge over the Internet (http://www.measuredhs.com/data).

Important information needs include:

• Reproductive intentions of migrants, refugees, and internally displaced persons.
• How dislocation and adaptation change reproductive intentions (119).
• Knowledge and behavior regarding contraceptive use (228).
• Interest in using reproductive health services (335). (Refugees, in particular, may consider other needs more pressing (213, 215).)
• Access to and use of available reproductive health services.
• Opinions of services.
• Exposure to and effectiveness of communication.
• How health care providers perceive and treat migrants, refugees, and displaced persons compared with other clients (97).
• Effectiveness of various approaches to providing reproductive health services (335).
• Relationships within refugee populations—for example, the role of opinion leaders in setting reproductive norms.
• Sustainability of reproductive health behavior among refugees after reintegration into their country of origin.

Information About Refugees and Internally Displaced Persons

Relief organizations often take surveys to provide themselves with baseline data on particular groups of refugees. For example, the International Rescue Committee (IRC) took a random survey of 400 Burundian refugee women ages 12-49 in a Tanzanian refugee camp. Survey results were analyzed in the field and discussed with representatives of the refugee community (218). Another IRC survey was fielded in Thailand, where 344 Karenni minority refugees from Burma were asked about their knowledge of HIV/AIDS. One finding was that many respondents did not know what a condom is (90).

Often such survey results are not disseminated but remain internal agency reports or published reports with small circulation (335). IRC, however, is preparing a centralized resource base of its own and other materials for general use (118). Also, John Snow Research and Training Institute (JSI) has published Reproductive Health for Refugees: A Selected Bibliography (155), listing information from relief agencies and other organizations.

While refugee agencies would undoubtedly prefer to have better data, the nature of emergencies means that data collection is difficult. When data are collected, mortality and morbidity are considered most important (41). Mdecins sans frontires (MSF) tries to set up a data collection system covering mortality and communicable diseases from the first day of an emergency. Such a system could also collect data on reproductive health attitudes and needs among refugees (32).

The United Nations now recommends collecting baseline data and conducting a KABP (knowledge, attitudes, behavior, and practices) survey on HIV/AIDS and a survey on the prevalence of STDs as soon as essential services are established for refugees (292). Recently, the Reproductive Health for Refugees Consortium has begun field-testing a guide to reproductive health needs assessment (242). This may prompt further production of comparable information about refugees.

The Women's Health Center at the Al-Bureij Refugee Camp is a beacon for women in the West Bank and Gaza Strip. Run for women by women, the center aims, among other goals, to reduce maternal and infant mortality and to promote responsible sexual behavior and family planning.

The center was established in June 1995, when the United Nations Population Fund (UNFPA) allocated about US$342,000 for a center for reproductive health care, social assistance, legal counseling, and community education. The center currently is being supported by the Culture and Free Thought Association, a local Palestinian nongovernmental organization, in cooperation with the Italian Association for Women in Development.

Since its inauguration in December 1995, the center increasingly is providing services previously unavailable to women in the area. It now provides many services, including reproductive health services—prenatal and postnatal care, safe delivery care, family planning—as well as legal assistance and, most recently, exercise programs to increase fitness.

The center also provides counseling for women's mental well-being. Iman Okasa, the center's psychologist, said, "Women often complain of physical ailments, unaware that they are usually suffering from stress-related problems. Under the difficult circumstances the Palestinians have lived through, emotional support is sometimes lacking." Previously, there were no social workers or psychologists working in the camp or even in the surrounding area. In most instances, it is assumed that the strong family network is adequate to support women.

Female teenagers are an often neglected group in this society, especially since many health programs for women focus on maternal health. This situation is exacerbated by the common belief that this vulnerable group can best be protected through strict family codes. Within this framework, issues that are traditionally taboo, such as incest and rape, go unmentioned in an attempt to safeguard the family's honor. But teenagers now have a place to turn. "We have been able to provide an environment that is very conducive to the discussion of these issues in a very confidential forum," Okasa said.

Contrary to the expectations of many, the men from the Al-Bureij Refugee Camp have supported the program and have even attended some center activities. Many have encouraged their wives or daughters to attend because they are comfortable with the center's work.

Lama Hourani, the director of the Women's Health Center, said it is the first of its kind in both the West Bank and Gaza Strip. All the services are located at the same place and are provided for women, by women, based on a comprehensive approach to the well-being of women. "We have been very successful," she noted. "Since our establishment last January, 2,200 women have become regular visitors to the center. We also conduct home visits to introduce the center and its services to the women and also follow up with them. Currently, we visit 10 to 15 pregnant women a month to see how their pregnancies are progressing, and we visit approximately 10 other women to discuss family planning issues."

Sabah Ammer is a regular visitor at the center, where she meets with her gynecologist. "In the past," she said, "the only alternative was UNRWA [United Nations Relief and Works Agency for Palestine Refugees in the Near East]. The services provided by UNRWA are very beneficial, but this is the first time that we are actually receiving individual attention. The doctor here spends a lot of time talking over our problems with us. If one method of family planning does not work for us, she will recommend another type, teach us how to use it, and keep working with us. These visits are free, and we usually don't need to wait because appointments are all arranged beforehand."

In 1995, following the International Conference on Population and Development (ICPD) in Cairo, the Inter-Agency Symposium on Reproductive Health in Refugee Situations met. In addition to UNHCR and UNFPA, UN representatives included the United Nations Children's Fund (UNICEF) and the World Health Organization (WHO), along with about 50 nongovernmental organizations and academic institutions (310). Symposium participants established a goal of strengthening reproductive health services in all refugee situations within five years.

As a result of this meeting, the Inter-Agency Working Group (IAWG) was formed and is working to strengthen reproductive health services. The IAWG is made up of 25 humantarian agencies. Also, following the symposium, a manual on providing reproductive health care to refugees was drafted (299). It is being field-tested in 1997 and will be revised early in 1998 (53). This manual, based on WHO standards, guides field-based health professionals implementing comprehensive reproductive health services in refugee situations. It also discusses reproductive health needs of adolescents and the rights of refugees relating to reproductive health.

A second manual drafted soon after the symposium was the Refugee Reproductive Health Guide to Needs Assessment and Evaluation (242), prepared by the Reproductive Health for Refugees Consortium. This manual focuses on procedures for assessing the reproductive health needs of refugees in the field. It is being field-tested in sites in Azerbaijan, Guinea, Mozambique, Pakistan, and Thailand (12). In addition, the Andrew W. Mellon Foundation has funded WHO to produce a technical guidelines manual (189).

The Reproductive Health for Refugees Consortium began meeting informally in late 1994 and was formally organized in early 1995. It consists of five organizations: John Snow Research and Training Institute (JSI), the International Rescue Committee, CARE, Marie Stopes International, and the Women's Commission for Refugee Women and Children. Established and funded by the Mellon Foundation, the consortium and its individual members work through advocacy, assistance, and information to see that reproductive health care is included in programs serving refugees.