Integration. If migrants, refugees, or internally displaced persons are well integrated into a larger community—as are refugees in Belize and Côte d'Ivoire, for example—programs probably should expand existing services to meet rising demand while incorporating a component to meet special needs, rather than develop new services for the new population. If the new arrivals live separately, however, as in refugee camps or culturally isolated neighborhoods, it may be necessary to build new services specifically for them.

Camps for refugees and internally displaced persons present a special case. Providing good services in such circumstances can be difficult because camps are intended to be temporary and indeed should disappear as soon as possible. Still, many camps last for years and thus should become equipped to meet a range of reproductive health care needs.

Eligibility. Laws in some countries prevent international migrants, especially those who are undocumented, from using publicly funded health services and threaten them with deportation if they seek health care (142). In places where residence permits are required, migrants without them are not eligible for government-provided services. Similarly, refugees who settle in existing communities may find access to the local health system limited by their legal status as well their poverty (32, 49, 94, 117, 254, 335).

Some countries provide refugees living in the community with access to local health care. In Guinea, for example, refugees from Liberia and Sierra Leone are permitted to use the national health system, with support from the UNHCR (188). In Kenya refugees are given certificates entitling them to services (56). In Belize all registered refugees are entitled to the same social services as the local population, including health services (334).

Differences and change. How different are new arrivals from others in the area, and how likely are they to adapt quickly? Some migrant groups adapt quickly to new situations, while others continue to speak their own language and retain their cultural identity for many years. Obviously, to be effective, reproductive health information and services must reflect the beliefs and practices of clients, so providers will need to address groups that adapt slowly differently from groups who adapt quickly (128, 192).

As noted, most urban family planning programs that reach migrants from rural areas should focus on recent migrants, who are least likely to have adapted to urban life and most likely still to resemble rural residents (see Knowledge and use by migrants' length of residence in Chapter 2.3). In some rural places, including parts of sub-Saharan Africa, community opposition to family planning remains a powerful force (106, 123). Attitudes are more positive in urban areas, where most people prefer to have smaller families.

Vulnerability. Many refugees and displaced persons and some migrant groups are vulnerable to abuse and may have experienced trauma during their move. Female refugees, especially those who are unaccompanied by a male, fare worst. In particular, victims of war and genocidal conflicts require immediate, continuous attention to posttraumatic distress and often need counseling for rape, loss of family members, or other hardships (128).

Previous experience with reproductive health. In emergency situations, it is important to provide reproductive health services immediately. Thus programs must quickly assess how much experience their new clients have had with family planning and other reproductive health care. The Reproductive Health for Refugees Consortium (see The Emergency Phase, Chapter 6.1) is encouraging development of a "refugee early warning system," using existing information about the refugees' culture to gauge the needs of the refugee group (32, 53, 128). With rural-to-urban migrants, knowing what reproductive attitudes and behavior are typical in the rural areas, as well as in urban areas, may help anticipate needs for care.