People move for many different reasons, and their circumstances vary widely. Still, they are alike in three important ways:

• Disruption. Most have left behind the support of traditional values, extended families, friends, and familiar ways of life. With limited means, they face new and uncertain situations.
• Differences. Culture and language often set them apart from their new neighbors. Reproductive attitudes and behavior often differ as well.
• Difficulties of access. Many are ineligible for health care benefits, unfamiliar with family planning programs, and unable to obtain information easily.

• Contraceptive access and use are limited. Recent migrants are less likely than other urban residents to use family planning. Attitudes explain part of the difference, but access is often a problem. Among contraceptive users, rural-to-urban migrants are more likely than urban nonmigrants to travel at least an hour to reach the nearest source of modern contraceptives.
• Risks of HIV/AIDS and other sexually transmitted diseases are high. The disruption of family and community life during moves, especially in situations of poverty and crisis, increases risky sexual behavior and exposure to STDs.
• Safe motherhood is difficult. Among refugees and internally displaced persons, childbearing can be life-threatening. During emergencies women often lack adequate food, shelter, and sanitation. Prenatal and delivery care often are minimal, and emergency care may be hours away.
• Violence against women is frequent. Women who move are especially vulnerable to sexual abuse. Among refugees, rapes occur frequently. Some women may have no choice but to trade sex for protection, money, and food.

In refugee emergencies the burdens of caring for huge numbers of people on short notice have prevented relief agencies from paying much attention to reproductive health needs. Although camps are meant to be temporary, most refugees no longer are in emergency situations. Therefore, relief agencies and reproductive health care providers are starting to find ways to address the continuing reproductive health needs of refugees and internally displaced persons—including prenatal, delivery, and postnatal services; STD prevention and treatment and HIV prevention; and family planning information, counseling, and services.

People Who Move: New Focus
      for Reproductive Health Care

Today millions of people are moving—some from rural to urban areas, others across national borders, some in search of opportunities and others fleeing disorder and danger at home, seeking refuge wherever possible. Clustered on the margins of cities or culturally isolated within them, housed in camps that were intended to be temporary, or without homes at all, migrants, refugees, and internally displaced persons are among society's most vulnerable people.

Although estimates of the total number of rural-to-urban migrants in the world are uncertain, perhaps about 16 million people migrate each year from rural to urban areas of developing countries, excluding China. This figure is derived from a recent United Nations assessment of the percentage contribution to urban growth of migration plus reclassification of territory from rural to urban status in 27 developing countries in the 1980s (288). The estimate of 16 million by Population Reports assumes that this percentage held true for the developing world as a whole and continued into the 1990s.

Also, an estimated 2 to 4 million people migrate internationally each year (235). An estimated 125 million people or more, about one in every 50 people, are living outside their country of birth.

In addition, some 18 million people, almost all in developing countries, have fled their home countries. About 15 million are formally recognized as refugees. An estimated 20 million more are considered to be internally displaced persons: they have fled their homes but remain within their own countries (322). (For definitions of migrants, refugees, and internally displaced persons, see sidebar, Comparing Migrants, Refugees, and Internally Displaced Persons).

• Disruption. Whatever their reasons for moving, to varying degrees the lives and circumstances of virtually all migrants, refugees, and internally displaced persons have been disrupted. They have left behind the support of traditional values, extended families, friends, and familiar ways of life and must deal with a host of new challenges. Refugees and internally displaced persons, in addition, have often lost their possessions, their jobs and income, their social status, and even their human dignity in the move (100, 265). People who have been dislocated face many risks to their health, including their reproductive health.
• Different characteristics. People who move often differ from the people in places to which they move—in their age, socioeconomic status, financial circumstances, and sometimes even culture and language. Not all mobile groups are alike, of course, nor do their characteristics necessarily mean that their need for reproductive health services is greater than that of other groups. Nevertheless, it is important that programs know more about migrants, refugees, and internally displaced persons in order to tailor information and services to meet their specific needs.
• Difficulties gaining access. People who move need reproductive health care but often lack access to services (25, 228, 287, 308, 318, 344). For example, they may be ineligible for health care benefits, unfamiliar with family planning programs and other services, unable to obtain information easily, and uncertain where to turn.

Some countries have recognized the presence of large numbers of migrants and have moved to provide reproductive health services (94, 208, 254, 275, 337). For example, China has acknowledged the need to provide better family planning services to its migrant "floating population" of some 80 million people (122), while in the Dominican Republic an AIDS prevention program and in Portugal a family planning program have focused on migrant groups (14, 121).

The reproductive health needs of refugees and internally displaced persons have received little attention until recently (74, 308, 323, 325). The burdens of providing for huge numbers of dislocated people on short notice, often with limited funds, have largely precluded attention to anything except emergency needs for food, shelter, and sanitation. Recently, however, the reproductive health needs of refugees are being recognized (242, 299, 304, 332). Similarly, in Azerbaijan, Sri Lanka, and elsewhere, recent reproductive health care projects have focused on internally displaced persons (117, 216).

In Africa migration from rural areas accounted for as much as half of all urban growth during the 1960s and 1970s and about 25% of urban growth in the 1980s and 1990s (42, 288). In Asia, excluding China, about 40% of urban growth in the 1960s, and over 45% in the 1970s and 1980s, has been due to migration and reclassification of territory from rural to urban (140, 284, 288). In Latin America migration from the countryside, along with reclassification, caused about 40% of urban population growth from the 1950s to the 1970s and about 35% in the 1980s (272, 288).

Given the steady flow of migrants over the past several decades, it is not surprising that migrants and their families now comprise a substantial percentage of urban residents (44, 104, 283, 289). A study using data from the Demographic and Health Surveys (DHS) for 14 countries in Africa found that, among married women of childbearing age living in urban areas, between 22% and 55% had migrated from villages and towns within the past 10 years (44). (For a description of DHS data concerning migrants, see sidebar, Understanding DHS Data on Migrants.)

Urbanization has been a powerful trend in developing countries. Just over 25% urban in 1975, developing countries were nearly 40% urban by 1995 (289). The number of people in urban areas of developing countries has risen from about 800 million in 1975 to about 1.7 billion today. Some developing-country populations have already become largely urban. In Latin America and the Caribbean seven countries are at least three-fourths urban—Venezuela (92%), Uruguay (90%), Argentina (88%), Chile (84%), Brazil (78%), Cuba (76%), and Mexico (75%). In North Africa and the Near East, Libya is about 85% urban, and Saudi Arabia, about 80% urban (289).

The world's population, estimated by the United Nations to be 45% urban in 1995, is projected to be nearly 60% urban by 2015. By 2015 over half of people in developing countries will live in urban areas (145, 289) (see Figure 1). By then the estimated urban population of the developing world will exceed 3 billion. Of these, over 1.2 billion will be living in "million-plus" cities. Between 2015 and 2025, for the first time ever, the rural areas of developing countries will begin to decline in population (289). The population of the developed countries, already about three-quarters urban, will become even more urban, rising to a projected 80% in 2015 (289).

Refugees. At least three-fourths of the world's refugees are in developing countries (235, 290). Africa and the Near East each contain over 30% of the total—more than 5 million in each region (235, 322). Africa had only about 400,000 refugees in 1960 (187), but the continent has seen large-scale refugee movements in recent years. Refugees sometimes move in both directions between neighboring African countries. For example, in 1995, 15,000 refugees from Mauritania lived in Mali, while 35,000 from Mali lived in Mauritania (235, 322).

Among refugees in the Near East, Palestinians are the largest group. Most have settled in Jordan, Lebanon, Syria, Gaza, or the West Bank. The second largest refugee group consists of Afghanis who fled to Iran and Pakistan when the Soviet Union intervened militarily in Afghanistan in 1979. In 1995 Iran had about 2 million refugees, more than any other country. Two-thirds of them were Afghanis (235, 290) (see Table 1).

Other regions have fewer refugees, but several countries have substantial numbers, nonetheless. In Asia, for example, Pakistan has an estimated 870,000 refugees, mostly from Afghanistan. Of the estimated 320,000 refugees in India, over one-third are from China. Most of the 100,000 refugees in Nepal are from Bhutan.

Internally displaced persons. Many countries have substantial numbers of people who have fled ethnic or religious strife, civil disorder, and other threats in their communities and sought safety elsewhere within their own country (see Table 2). Sudan, after years of civil war, contains more internally displaced persons than any other country, an estimated 4 million people, or about one-seventh of its total population. Other countries that are estimated to have at least 1 million internally displaced persons are Angola, Iraq, Liberia, Sierra Leone, Turkey, and Bosnia and Herzegovina, where an estimated one-quarter of the population are either refugees or internally displaced persons (255, 322). In 1993 an estimated 12% of Rwanda's people were displaced within the country (205).

Fertility and Family Planning

When people migrate from rural to urban areas, their fertility and family planning behavior at first is likely to differ from that of long-term urban residents. The longer they remain in urban areas, however, the more their behavior becomes like that of other urban residents. Similarly, the fertility and family planning status of refugees and internally displaced persons is likely to differ, especially at first, from that of people in their new areas.

Selection. Rural-to-urban migrants are more likely than people who remain in rural areas to have socioeconomic characteristics that in most countries are associated with interest in controlling one's own fertility (42, 201). Rural people who choose to migrate often do so because they want to change their lives for the better. Controlling their own fertility can be an important part of this change. Also, large families may find it harder to move than small families.

Disruption. In itself, the act of migrating typically reduces fertility for a time because it delays marriage, separates spouses, and postpones childbearing (114, 201, 303). Spousal separations of two years or more reduce the number of children that a woman has over her lifetime (234). Some new migrants, however, may still have more children than they would like because they are not aware of family planning as an option (241), do not know about reproductive health services, or lack access to them (40, 43, 107). Disruption is an especially important force in the case of refugees and displaced persons. Typically, fertility of refugees drops in the first six months after flight and then begins to climb steadily (280).

Adaptation. As migrants settle into urban areas, new influences and new social networks change their lives. Like their diets, jobs, and interests, people's fertility preferences, family planning practices, and other reproductive behavior change as they become integrated into urban life (344). Migrants tend to be innovative and flexible (19, 33, 158). Thus it may not take them long to learn about hospitals, clinics, and other urban reproductive health care services (344).

Urban life erodes the social underpinnings of high fertility, which are much stronger in rural areas. For example, in rural Africa supports for high fertility include polygamous marriages, the high social status associated with bearing many children, a woman's obligation to her husband's parents to bear children, and the use of child labor in agriculture. These supports are weaker in urban areas, where monogamy is usually the norm, it costs more to raise children, and children do not make as much economic contribution to the family (42).

Adaptation to urban norms may affect a woman's fertility and her child's health if she no longer breastfeeds a newborn child. Breastfeeding tends to postpone the next pregnancy as well as to provide good nutrition to the infant children. While rural-to-urban migrants as a group breastfeed longer than do urban nonmigrants (43, 272), the duration of breastfeeding falls as migrants' length of residence increases (112, 326).

Family planning programs may need particularly to reach out to the most recent migrants, who are least likely to have adapted to urban life. Most migrants adopt urban fertility norms within a few years, and their fertility rate falls (42, 175). Studies in selected sub-Saharan African cities and a few cities elsewhere have found that, after one or two years of residence in an urban area, migrants from rural areas use contraception more (42, 106,178).

Temporary migrants. People who migrate to urban areas for only a short time often do not fit the selection-disruption-adaptation pattern. Some newly arrived migrants plan to return home soon, while others are ambivalent about the future, waiting to see how things work out in their new place of residence. Still others, known as "target migrants," come to cities only to achieve a particular goal, such as getting an education or earning a certain sum of money (140).

The fact that temporary migrants do not settle in any one place for long makes it difficult for social service programs to reach them (158, 331). Experience in Sri Lanka, however, indicates that, if family planning services are available, transient migrants often do become interested in using them to avoid unwanted pregnancies (215).

Diminishing differences. In some developing countries rural residents are becoming more like urban residents as the ideas and amenities of urban areas spread to rural areas. Radio and television now reach rural areas as well as cities (303). Differences between cities and the countryside in mortality, fertility, and educational attainment have diminished (140). Although the gaps between rural and urban life may be narrowing, there are still important differences in reproductive health needs and behavior between rural-to-urban migrants and urban nonmigrants.

DHS data also show that, among urban women ages 30 to 34, the average number of children ever born is higher for rural-to-urban migrants than for urban nonmigrants in 19 of 22 countries, with differences of more than one child per woman in Morocco, Peru and Senegal (see Figure 2). Such statistics include births that occurred both before and after migration (32, 274). Also, more rural-to-urban migrant women, on average, consider a larger family ideal than do native urban residents. This difference occurs in most of the 22 DHS surveys studied by Population Reports, but most differences are quite small.

Fertility of refugees and internally displaced persons. Data on the fertility of refugees and internally displaced persons are few. The Women's Commission on Refugee Women and Children observes, however, that "women in refugee sites throughout the world—many of them in questionable health and with few or no material resources—are having large numbers of pregnancies at closely spaced intervals" (335). For example, among about 739,000 refugees from Rwanda in five camps in Goma, for January to September 1996, the crude birthrate was 41 per 1,000 population (298)—high by world standards and about the same rate as for sub-Saharan Africa as a whole.

Refugee groups differ substantially in fertility. For example, among women in refugee camps in Thailand, birthrates were much lower among lowland Laotians than among the Hmong. The Hmong married younger than the lowland Laotians. Only 3% of Hmong women were using contraception compared with 42% of the lowland Lao. On average, Hmong women wanted 6.2 children compared with 3.4 children among the lowland Lao (69).

Refugee fertility may be elevated when couples fear that children will not survive to adulthood, or they want to replace children who died or became separated from the family during the emergency (126, 327). Also, food and other benefits in camps may be based on family size, or refugee leaders may discourage use of contraception because they believe people should have large families (335). Many people in emergency situations may want to have fewer children, however, and thus are motivated to use contraception (117, 255, 335).

Knowledge of contraception among migrants. In general, the urban poor, many of whom are migrants, know less than other urban residents about family planning and modern contraceptives (108, 192). According to DHS data, in 19 of 22 countries studied, rural-to-urban migrants were less able than urban nonmigrants to name at least one modern contraceptive method. In most of these countries the differences were quite small, and in all countries at least two-thirds of migrants knew about a modern method.

In all but 2 of the 22 countries, rural-to-urban migrants could name fewer contraceptive methods than could urban nonmigrants. Knowledge of a greater number of methods is closely correlated with contraceptive use (31) and inversely correlated with levels of unmet need for family planning (247). Also, in most of the countries studied, a lower percentage of rural-to-urban migrants than of urban nonmigrants knew where to obtain a modern contraceptive method.

Awareness of modern contraceptive methods has become widespread even in rural areas in many countries. In 10 of the 22 countries studied using DHS data, more than 90% of rural women knew at least one modern contraceptive. Still, in some cases, awareness of contraception is substantially lower in rural areas than in urban areas. In 9 of the 22 countries studied, the percentage of rural women of reproductive age who could name a modern family planning method was at least 20 points below the comparable percentage of urban women. Where family planning programs are as strong in the countryside as in big cities, however, the level of contraceptive knowledge among rural-to-urban migrants can be as high as that of urban nonmigrants—as in Indonesia (179).

Use of contraception among migrants. In general, rural-to-urban migrants are less likely than other urban residents to use contraception. This was the case in 17 of the 22 countries analyzed on the basis of DHS data. Usually, the differences are small—less than 6 percentage points (see Figure 3). Another study of DHS data for Bolivia and Peru found that native urban residents used modern methods of contraception most, followed first by long-term rural-to-urban migrants, then recent migrants, and finally rural residents who had not migrated. This pattern held true when the study controlled statistically for marital status, age at marriage, and women's education (272).

Rural-to-urban migrants also are less likely than urban nonmigrants ever to have used modern contraceptives. For example, in Malaysia 53% of urban nonmigrants had ever used contraception compared with 38% of migrants (345). Also, in 17 of 22 countries studied with DHS data, a smaller percentage of migrants than of nonmigrants in urban areas had ever used contraception.

Knowledge and use by migrants' length of residence. Grouping all migrants together masks crucial distinctions among migrants themselves, both because of the process of adaptation and because of differences in age and family status among migrant groups. On average, long-term migrants are older and more likely to be married or to have been married. They have had more time and more reason to learn about and use contraception.

In some countries long-term migrants (those who have lived in the urban area for at least 10 years) are more aware of modern contraceptives than recent migrants (those who have lived in the urban area four years or less). In 6 of 18 countries analyzed with DHS data—Burkina Faso, Ghana, Nigeria, Pakistan, Peru, and Senegal—long-term migrants were more likely than short-term migrants to be aware of at least one modern contraceptive method by a margin of at least 10 percentage points. Awareness was generally high for both groups, however. Long-term migrants also tended to know more about how to find contraception.

The longer that migrants from rural areas live in urban areas, the more likely they are to use modern contraception. This is the case in 17 of 18 countries studied using DHS data. Differences in contraceptive use by length of residence often are dramatic. In the Dominican Republic, for example, 50% of long-term migrants were using modern contraceptives compared with 26% of recent migrants (see Figure 4).

Refugees and internally displaced persons. Little is known about contraceptive knowledge and use among refugees and internally displaced persons. A study in Sri Lanka found that internally displaced persons had relatively little knowledge and low rates of contraceptive use compared with the general population. While awareness of at least one contraceptive method was fairly common among these displaced persons, accurate knowledge about different methods was rare (225).

The family planning status of refugees and internally displaced persons is likely to reflect the state of family planning programs in their home communities, which may be different from the facilities available in and around camps. Thus information about family planning and other reproductive health programs in the areas from which refugees come is important to meeting the needs of these groups (280). For example, refugees who are using IUDs or Norplant implants may face problems when they want these methods removed. Others may run low on supplies of oral contraceptives or condoms and have no place to go for resupply, may not know where to go, may be unable to speak the language, or may fear male providers.

Reproductive Health Care

The reproductive health status of many migrants, refugees, and internally displaced persons suggests several reasons for concern:

• AIDS and other sexually transmitted diseases (STDs) spread more rapidly as populations become more mobile (20).
• Safe motherhood is nearly impossible for refugees and displaced persons, especially in the early phases of an emergency, because people live in conditions of extreme dislocation, minimal shelter and food, poor sanitation, and physical danger (185).
• Violence against women is widespread during refugee and internal displacement movements (132, 143, 194, 218). When women and children move, they are often alone and powerless and thus at risk of becoming sexual prey (257).
• Unsafe abortions are common among refugees and internally displaced persons. Service providers can help avoid abortions by providing effective contraception and should be ready to deal with complications of unsafe abortion.

The more people move, the faster AIDS and other STDs, like other diseases, can spread. Mobility itself has been considered an independent risk factor for HIV infection (88). While little research has been conducted on the prevalence of STDs among migrant groups (91), studies show that the spread of HIV often coincides with migration patterns.

Usually, HIV appears first in urban areas and then diffuses to rural areas along major road networks. In Côte d'Ivoire, for example, HIV/AIDS has spread outward from the capital city, Abidjan, where almost half the population are immigrants from surrounding countries (4). AIDS has spread along transportation routes from Zambia, Zimbabwe, Malawi, and Mozambique to South Africa (267) and along the Mombassa highway from the Indian Ocean to the former Zaire (4).

A study in Kenya found that men who migrated between urban areas were more than twice as likely as nonmigrants to engage in high-risk sexual behavior—that is, to have more than one sex partner while not using condoms. It was not clear whether their behavior was more risky because they moved or whether those who moved were prone to more risky sexual behavior than others (46).

Other factors may increase risk for migrants and refugees. Communicable diseases, including STDs, spread most quickly in conditions of poverty, powerlessness, and social instability. Such conditions often are found in refugee emergencies (292, 308). Also, migrants often settle in areas with high prevalence of HIV infection, are exposed to intravenous drug use, and may be in poor health (127). The disruption of social ties and family life that occurs during moves, especially in situations of poverty and crisis, also increases risk of disease, as migrants find new sex partners. Sometimes women have no choice but to sell sex for protection, money, food, and other goods (32, 103, 142, 269, 292).

HIV high-risk groups and mobility. Many people who move frequently have a high risk of HIV infection, including truck drivers and other transportation workers, sex workers, and seasonal agricultural workers and other temporary migrants (4, 21, 101, 127, 220, 303).

Although not considered temporary migrants, long-distance truck drivers are of particular concern to disease control programs because they often are at high risk and can spread STDs long distances. They travel frequently, often to areas with high levels of HIV, and, because they are away from home for long periods of time, they may have many different sex partners (267).

For example, among 400 West Bengal long-distance truck drivers surveyed, more than 60% reported having visited sex workers, 36% had never heard of AIDS, and only 22% were regular users of condoms (127). About one-half of truck drivers arriving in Kigali, Rwanda, from Mombassa and Nairobi, Kenya, were HIV-positive, according to a 1994 study (205). In a study of 200 adolescents who frequented truck stops in Kenya, half the boys and almost one-third of the girls reported having had at least one STD (127).

Many sex workers move from place to place, whether voluntarily or involuntarily. For example, women from Cambodia, Laos, Myanmar, and Vietnam work in brothels in Thailand. Sex workers from Thailand and the Philippines work in Japan. Thai women become sex workers in Singapore, and Nepalese women work in India, where 35% or more of sex workers are infected with HIV (142, 180). Sex workers may spread HIV from cities to rural areas when they return home. In Ghana many rural women who left for Côte d'Ivoire and became sex workers brought HIV home with them to their villages, which now have a high prevalence of HIV (5, 87).

Often, boom towns and tourist centers that attract temporary migrants and visitors also attract many sex workers, to whom men away from their spouses or usual partners may turn (20, 91, 142, 172, 269, 341). Male migrants who go to sex workers infected with HIV can transmit the virus to other sex workers and also give the virus to their wives or other female partners at home when they do not use condoms (46, 240). In 1990 a study in KwaZulu/Natal province, which is a major source of migrant workers to the mines of South Africa, found that migrant men had twice the HIV rates of nonmigrants, while women who attended prenatal clinics in the province had twice the national level of HIV infection (20).

AIDS has spread even to remote countries with conservative norms about sex (255). For example, in the Pacific island nation of Kiribati some men who leave the country to work on foreign ships have become infected with HIV and have spread the virus upon returning home (39).

Border controls. Some countries have charged international migrants and foreign visitors with introducing HIV (102, 276). China has held foreign tourists responsible for the appearance of the AIDS virus in that country, although many HIV cases in China have involved returning migrants who had contact with sex workers elsewhere (154). In Ethiopia refugees, along with sailors and sex workers, have been blamed both for the introduction of HIV into the country (282) and for spreading the virus within the country (142). Mexico's Health Minister recently pointed to Mexicans returning home from the United States as the reason that the incidence of AIDS was increasing in rural areas of Mexico, especially where there is substantial migration to the US (243). An estimated 25 percent of AIDS cases in Mexico occur to individuals who have been temporary migrant workers in the United States (127).

A few countries have tried to stop the spread of AIDS by preventing people suspected of being infected with HIV from entering the country. In 1992 the US would not admit HIV-positive participants to the World AIDS Conference in San Francisco. Countries that have instituted border controls of various sorts include India (151), the Gulf States (186), South Africa (20, 67), Cuba, and Iraq (276).

Border controls are ineffective, however, and only create a false sense of security and detract attention from the need to reduce high-risk sexual behavior within the country. The World Health Organization (WHO) also has taken a stand against mandatory HIV testing in refugee situations, arguing that the tests can be inaccurate and do not prevent the spread of the disease (299). Mandatory testing may even increase the spread of HIV, if unsterile needles are used for drawing blood for tests, by infecting the people being tested (60).

Refugee movements and AIDS. Refugee movements have contributed to the spread of HIV/AIDS and other STDs. When nearly 2 million refugees who had fled in the 1980s to Malawi, which has a high HIV rate, returned home to Mozambique, the incidence of HIV began rising in Mozambique, where it was previously rare (29, 142). Liberian refugees in Côte d'Ivoire and Guinea, Rwandan and Ugandan refugees in the former Zaire, Laotian and Cambodian refugees in Thailand, Sudanese refugees in Uganda, and Ethiopian refugees in Sudan have carried HIV home with them, after having been infected during their flight (320).

Relatively little attention has been paid among humanitarian agencies to treatment of STDs in refugee situations. Among eight refugee camps in the Great Lakes Region of East Africa, only the two oldest camps provided comprehensive treatment at separate STD clinics; these served mostly men, who were reluctant to bring in their wives or other partners for treatment (222). When attention is paid to STDs and HIV/AIDS in refugee situations, it is often on a case by case basis—for example, after being identified during pregnancy or childbirth—rather than as part of a health education effort, and little attention is given to treatment of partners and to follow-up (255). There is little attention to counseling (222).

The situation is changing. Recently, the Joint United Nations Programme on HIV/AIDS published Guidelines for HIV Interventions in Emergency Situations (292). This publication discusses why HIV/AIDS should be given high priority and describes the services that are required to cope with the problem, including provision of condoms, education about HIV/AIDS prevention, and STD treatment.

Adopted in 1987 by the United Nations Children's Fund (UNICEF), the United Nations Population Fund (UNFPA), and WHO, the International Safe Motherhood Initiative seeks to reduce maternal deaths by at least one-half by the end of the century (113, 185). The Initiative does not specifically mention migrants, refugees, or internally displaced persons, nor have many studies focused on safe motherhood practices among migrants. A study in Bolivia found that migrants were less likely than others to have had prenatal care or a trained attendant during delivery (27). In Sabah, Malaysia, poor access to reproductive health services, as well as lack of interest, helped explain why migrants were much less likely than the general population to have prenatal care. Migrants who received any prenatal care at all received it later than the general population (345).

Data do not exist on safe motherhood practices among refugees or even on refugees' morbidity and mortality related to pregnancy and childbirth (299, 320). Observers have reported, however, that pregnancy and complications of delivery are leading causes of illness and death among refugee women of childbearing age when maternal care is unavailable (195, 302). When complications of pregnancy occur, for example, camp medical provisions are likely to prove inadequate, and hospitals may be too far away (222). Two recent publications, drafted following the Symposium on Reproductive Health in Refugee Situations in 1995, draw attention to safe motherhood for refugees (242, 299, 310) (see sidebar International Relief Agencies).

Except for emergency obstetrics, safe motherhood initiatives may not be too difficult to organize in refugee camps. It is often possible, for example, to find traditional birth attendants (TBAs) among refugees who could be included in a safe motherhood system working together with trained midwives (32). Among refugees in Kenya, TBAs were trained in safe motherhood care, while refugee health workers were trained by the International Rescue Committee (IRC) to provide family planning (12). In three camps in Baluchistan, TBAs among the refugees received training and were able to provide better services (207).

Women have been subjected to violence at all stages of refugee or internal displacement situations (218). Women may find themselves forced into sex in order to gain access to even basic needs, such as food (142, 253, 292). In some instances rape has become a deliberate method of persecution (218, 271, 292).

A recent survey of Burundian refugees in Tanzania found that over 25% of women in the established camp of Kanembwa had faced some sort of violence. More than 150 women reported that they had been raped or sexually harassed since the start of their flight. Relief workers said that women in the other camps also had experienced such attacks but were afraid to report them (222). Many rapes go unreported (52). In Uganda one study found that half of women who had been raped had not previously told anybody about it, even as much as seven years afterwards (271).

The situation among refugees from Burundi in camps in Tanzania may be typical. Burundian refugees tend to remain silent about sexual violence because it is severely stigmatized in Burundian culture. The survivor who steps forward may be blamed, ostracized, and punished; she may be unable to marry or stay married; she may lose access to ration cards. Lack of knowledge of the procedures and laws to protect victims is a further block to reporting violence (218, 222).

Boys living in camps, and to a lesser extent men, also are vulnerable to sexual and gender violence (126, 218, 255, 292). Among the Burundian refugees in Tanzania, for example, an open invitation to come forward with reports of sexual violence produced 10 responses from males under the age of 18 (218).

Dealing with violence. Violence against women refugees is so common that all camps should have programs to deal with it (222). The United Nations High Commissioner for Refugees (UNHCR) advises field staff to assume that such violence is a problem unless shown to be otherwise (299). To help refugee camp personnel combat sexual violence, UNHCR has published Guidelines on Prevention and Response—Sexual Violence Against Refugees (296).

Recognizing the problem and urging women to come forward are important ways to begin. After the IRC established a project in a Tanzanian camp to reduce violence against women, the number of women who came forward to report incidents of violence increased markedly (12, 218). Since violence in refugee camps often occurs due to loss of traditional social supports, extreme stress, and feuds among refugee factions, camp personnel should address these underlying factors. Also, designing camps with safety in mind, better policing, and increasing the odds of punishment for offenders can help address the problems (299).

In refugee situations where women are subject to violence, empowering women refugees can help lessen the dangers (299). In Malawi, when women refugees became responsible for food distribution, complaints about being forced to give sexual favors in exchange for food largely ended (74). When a women's group formed in a Thai refugee camp in 1992, members of the group reported on incidents of sexual abuse and intervened in domestic violence cases (74). UNHCR now requires that representatives and field officers take into account women's needs in camp site planning (194, 299). These directives are not yet fully enforced, however (119).

Female genital mutilation. Female genital mutilation (FGM), or female circumcision, is practiced in as many as 28 African countries and in two or three countries outside Africa (138, 281). Organizations that study FGM report that there is almost no information on FGM among refugees. Anecdotal information indicates that it does occur among refugees from countries where FGM is practiced (16, 148).

The practice of FGM reflects deeply held cultural beliefs but nonetheless constitutes violence against women and especially against children, on whom it is practiced without their consent (281). FGM is painful, dangerous, and traumatic. Its consequences can be life-threatening for both mother and prospective offspring (138, 166). It cannot be condoned or justified "on the grounds of tradition, culture or social conformity" (299), and it has been condemned on the basis of both the health risks and as a violation of children's and women's rights at numerous international conferences. A network of local women's organizations in Africa has been working actively for more than 20 years to try to stop FGM (148, 166).

In Ethiopia a pilot project supported by UNHCR, in coordination with the Ethiopian Committee on Eradication of Harmful Traditional Practices, has been working with Somali refugees in camps to raise awareness of the harmful effects of FGM. Health workers have seen few complications of FGM since this project began (53).

While there are few statistics, and many abortions go unreported among groups of refugees and displaced persons, unsafe abortion appears to be common (12, 86, 118, 298). Few refugee camps are prepared to deal with complications, however. For example, among the eight refugee camps in the Great Lakes Region of East Africa, only one had facilities to treat women after miscarriage. Most complications were referred to district hospitals of the Ministry of Health. In these hospitals workloads are heavy, and equipment and medications often are inadequate (222).

Many unsafe abortions would be avoided if refugees, displaced persons, and migrants had better access to contraception—particularly women who are suffering complications of unsafe abortion or miscarriage. Emergency care and the offer of family planning counseling and contraceptive methods are needed (287).

Personal Characteristics

Knowing more about refugees, displaced persons, and migrants—including their demographic characteristics, social and economic status, and culture—can help service providers meet their needs (27, 158, 165, 178, 228). Reliable information about these groups is scarce, however (74, 116).

Many migrants cluster in certain neighborhoods of large cities, primarily in squatter settlements at the edges of the cities (40). People who live in urban slums and squatter settlements often have little access to health care and other services (83). Clustering, however, offers an opportunity for reproductive health care providers to focus information and services on migrant communities (178). Other migrants live together at their places of work—for example, in factory dormitories, where service providers may be able to reach them (137, 232) (See Reaching Out with Services in Chapter 5.3.).

New migrants from rural areas often settle among earlier migrants. They are drawn together by common ethnicity, the presence of family or friends, or by the fact that they are joining others from the same village or region. How this pattern affects migrants' adaptation is not clear. On one hand, the tendency for recent migrants to live among earlier migrants might slow adaptation to urban attitudes and reproductive behavior by sheltering new arrivals from urban influences. On the other hand, it could speed their adaptation, because earlier migrants have already "learned the ropes" and can help new arrivals adapt (252).

Surveys such as the DHS can provide some information about characteristics of rural-to-urban migrants. Almost all information about characteristics of refugees and displaced persons are based on assessments by relief agencies. Because refugee situations change quickly, even accurate information can soon become inaccurate (258). Reproductive health programs need to collect and analyze data themselves to learn more about the people who have recently arrived in their service areas (see sidebar, Research Needs for Planning Services).

Sex composition. Within developing countries, a growing share of rural-to-urban migrants are women, especially younger women (303). The trend reflects both the lack of jobs in rural areas and the increasing availability of jobs for women created by the labor-intensive manufacturing operations of multinational corporations. Also, many female migrants, particularly the young and single, work as domestics and in other service jobs available in large cities (165, 237).

Women often make up the majority of migrants from rural areas to the biggest cities, particularly in Latin America and, to a lesser degree, in East and Southeast Asia (27, 63, 140, 274, 316). Women also are beginning to comprise most of the flow to cities in Africa (192, 226)—a reversal of earlier patterns in the region (42, 104). In India, too, where men once dominated migration flows, rural-to-urban migration is becoming more female (140).

Concerning refugees, it has often been said that most are women and children (258). For instance, in mid-1995 the United Nations estimated that three-fourths of all refugees were women and their dependent children (308); in 1997 the United Nations Population Fund (UNFPA) stated that women and children make up 80% of refugees (302). A study of one refugee camp in Ghana reported that women and children made up over 70% of the total population of more than 13,500 people (80). These estimates are intended to stress the vulnerability of so many refugees, not necessarily to imply that most refugees are women.

In 1993 UNHCR began to make annual year-end estimates of the sex and age composition of refugee populations (258). The most recent report, covering data for 1993 to 1996, shows that the sex composition of refugee groups varies widely, even within a single country, and that it varies somewhat year by year (258).

The sex composition of refugees and displaced persons depends on the forces that have pushed people from their homes. For example, some refugee groups are mostly male soldiers. Other streams may be mostly women who have fled with their children for safety, while their husbands stayed behind to fight (258).

Among international migrants (not including refugees), men make up a slightly larger share—54%, according to the most recent estimate (293). Sending countries often restrict women's mobility, while in many receiving countries the demand has been predominately for men's labor (63). It is not possible to generalize further about the sex composition of international migration streams because groups of international migrants are so different from one another (48, 61, 63, 104, 140, 141).

Age. Like the populations of developing countries in general, most migrant populations are young. Migrants often are older than nonmigrants in the same area, however (84, 158, 236, 274). For example, in 19 of 22 countries studied using DHS data on urban women of reproductive age, a larger percentage of migrants than nonmigrants were over age 25.

Migration among women tends to peak at ages 15 to 24 (42, 104). Young women usually find it easier than older women to migrate because there are more jobs and because they have not yet married and established families. A second, smaller age peak occurs at around age 45, however. Women in their forties may be able to migrate more readily than women in their late 20s or 30s. Their family ties may have weakened after their children have grown, and they may also be widowed or divorced (104).

Among refugee groups, one estimate often used is that women of childbearing age constitute between 22% and 25% of the total (50). By comparison, in 25 countries with DHS data, the proportion of the total population between the ages of 15 and 49 ranged from 18% to 27% (23).

The United Nations has begun to provide information on the age composition of refugees (300). The coverage and the selection of age groupings are not detailed enough for planning purposes, however. The figures vary substantially from one year to the next. Moreover, summary data conceal large differences among refugee groups. In camps in Guinea-Bissau, for instance, 59% of refugees are children age 17 or younger. In camps in Benin, only 18% are children (300).

Marital status. The marital status of rural-to-urban migrant women varies widely by country, and there appears to be no pattern. In Senegal, Mali, Kenya, China, and many countries of Latin America, many migrants are single women (104, 122, 201, 338). In some African cities a substantial percentage of recent female migrants are unmarried or married but not living with their husbands (42). In other countries of Africa—Ghana and Tanzania, for example—married women are more likely than single women to migrate from the countryside to cities (104).

Unmarried migrant women often marry once they settle in new places. In 17 of 19 countries studied using DHS data, among women 20-to-24 years of age, higher percentages of female urban migrants than of urban natives were married. In some countries, however, the differences were small.

Literacy and formal education. People who migrate from rural areas to cities usually are more literate and better educated than other rural residents (174, 201). This is true of both men and women but especially of men (104). On average, however, rural-to-urban migrants are less literate and less educated than other urban residents (27, 239, 272). This fact reflects the tendency everywhere for schools to be concentrated in urban areas. Also, because international migrants (not including refugees) tend to seek new homes in more developed countries, they often have less education than the people in the countries to which they migrate (345).

DHS data for 22 countries show that in all but one country—Niger—literacy is lower among rural-to-urban migrant women of reproductive age than among female urban nonmigrants in the same age range. (The DHS data report current status rather than status at time of migration.) In Cameroon and Haiti, for example, nearly half of migrant women are illiterate compared with about one-quarter of nonmigrant urban women. In Pakistan nearly 80% of migrant women are illiterate compared with less than half of urban nonmigrant women (see Figure 5).

In some countries these differences are small, however. In Colombia, Kenya, and the Philippines, almost all urban women of reproductive age, whether migrants or not, can read. Only in Niger is illiteracy common among rural-to-urban migrants and urban nonmigrants alike.

Far more nonmigrant women of reproductive age than rural-to-urban migrant women have a secondary school education, DHS data show. In Bolivia over 60% of nonmigrant women have a secondary education compared with under 25% of migrant women. In Morocco the comparable statistics are about 40% for nonmigrants versus about 10% for migrants; in the Philippines, 80% compared with 60%; and in Kenya, about 50% compared with 40%. These differences reflect the fact that most adult migrants grew up in the countryside, where there are fewer secondary schools than in the cities, and where few women have an opportunity to obtain more than a primary education.

Educational status affects reproductive health status in several important ways. The more educated a person, the more likely she or he is to marry late (106, 192), to know about reproductive health services and their location (106, 174), to want fewer children (144, 192), to use contraception, and thus to have lower fertility (106, 192, 201, 245, 248). Reflecting these patterns, female rural-to-urban migrants with more education are less likely than migrants with little or no schooling to want large families, more likely to use contraception, and more likely to have lower fertility, according to DHS data.

Living standards. The low living standards of migrants, refugees, and internally displaced persons are one of the most critical reasons for their relatively poor health status. Many rural-to-urban migrants—although not all, of course—have low living standards compared with other urban residents (27, 345). In countries studied with DHS data, rural-to-urban migrants report fewer household possessions and amenities, such as refrigerators and toilets, than urban nonmigrants. They were more likely to live in houses with dirt floors.

Migrants make up widely varying percentages of the urban poor among 20 countries studied, from only 7% in Nigeria to 43% in Bolivia:*

Migrant women hold even lower-status jobs than migrant men and are more likely to work in the informal sector of the economy (104, 239). In developing countries women typically have a narrower range of job opportunities and are most often found in assembly industries such as garment manufacturing and in domestic service (63). Some have little choice but to become sex workers (227).

Language differences obviously make communication difficult and can discourage people from obtaining services (26, 91, 133, 241, 329). Mass-media messages about family planning, STDs, and other health care may not reach or mean much to migrants whose language and culture differ from those of the surrounding population (91). Different languages may not even have comparable reproductive health concepts (22). Those who do seek services may find it difficult or embarrassing to communicate and may not be able to ask for what they want or to understand fully what providers are asking or telling them (91, 241). Thus, in Guatemala, for example, Mayan women who had been displaced from their community would accept family planning information only from providers who could speak their language (183).

Culture and customs affect reproductive health and health care in many ways. For example, women who have moved from rural areas may prefer traditional birth attendants. Also, many people's ideas about how illness originates and women's customary health-related behavior during pregnancy and postpartum differ from Western medical views, which are more widely accepted in cities (26, 35, 84, 167, 171, 177, 181, 193, 197, 266). Pregnancy and childbirth can be extremely difficult for a woman living in a new country or in a refugee camp, lacking support of her extended family, unable to speak the local language, and assisted by male doctors in an unfamiliar setting (34).

Cultural differences among refugee groups can affect their interest in family planning, too. For example, among refugees in Thailand in the early 1980s, Laotian Hmong women were shy, knew little about contraceptives, and had very low levels of contraceptive use. In contrast, lowland Laotian women were open and receptive to new ideas. Much higher percentages knew about contraceptives and were currently using them (69).

The sex of doctors, clinic staff, and other health care providers can cause problems. In refugee camps most medical doctors are men (53, 135). In many cultures, however, women do not consult male doctors. For example, about half of today's refugees are Muslims, who generally want to be served by health providers who are members of the same sex (56, 254). Thus, in Bangladesh, Burma, Pakistan, Somalia, and Ethiopia, refugee women (and their partners) as a rule do not allow male medical personnel to examine them (60, 74, 135, 205).

Reproductive health care also may be influenced by the provider's perception of the clients' social status. Service providers who lack training in cultural sensitivity and interpersonal communication can discourage clients (77, 152). Untrained staff may inadvertently fail to respect traditional practices (214). Service providers are often better educated than their clients, and poor clients, including migrants, tend to receive the worst treatment (259). Lack of cultural training reveals itself in discrimination, insensitivity, and intolerance (35, 36, 170, 178, 251). The problem has been noted in refugee camps, where Western medical staff may lack cross-cultural skills (22, 147, 162, 177).

Overcoming cultural differences. There are many way to bridge cultural gaps between clients and providers. Programs should have enough female staff members to serve female clients whose beliefs prohibit seeing male health care providers (56, 97, 146, 242, 299, 320). Where migrant groups speak different languages than other clients and the service providers, interpreters may be necessary to improve access, especially when expatriates provide services, as in many refugee camps (97, 242). Professional staff with appropriate language skills are preferable, however, because most interpreters lack medical training and may also lack empathy for clients (84). Refresher courses and additional training for providers can encourage their sensitivity and build their interpersonal communication skills (77, 97, 112, 146, 229).

Problems of language and other cultural differences between service providers and clients can be reduced if field staff can be recruited from trained members of the community. In addition, it may be possible to recruit untrained volunteers among the clientele, who can be trained to explain family planning, distribute contraceptives, make referrals to clinics, and otherwise help clients make informed choices (69, 242). In Mauritius labor migrants are trained in their own homes on their own time (late evenings and Sundays) to become Sexual and Reproductive Health Agents. Because the trainers do not speak the migrants' native language, the training is provided for migrants who speak English; these migrants in turn inform their fellow migrants (49).

Because they often have suffered psychological trauma, refugees especially need someone sympathetic who will treat them as individuals and with respect (25). Furthermore, family planning may be an unfamiliar concept to some refugees. In Pakistan some refugee groups from Afghanistan have had virtually no experience with modern contraception and come from a culture in which family planning is not widely accepted. Counseling and service provision in such a situation requires a sensitive, gradual approach.

Health workers need to appreciate traditional beliefs while offering modern information and services. For example, some traditional practices are unhealthy for new mothers and their children, such as fasting after childbirth and not breastfeeding a newborn for the first two days. The better that service providers understand the cultures of their clients and can communicate with them, the better they can advise clients against such practices (11).

Taking Reproductive Health Care
     to People Who Have Moved

How can reproductive health care be improved for people who move? The first step is to assess their status, especially how they differ from other people in the area. Knowing their intended clientele, programs can find better ways to reach out to them and can serve them better.

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.

Nevertheless, as much as possible, health programs should anticipate migration and plan to provide services to the migrants. At the beginning of an irrigation project in the Kou Valley of Burkina Faso, for example, planners concluded that social and health services should be in place before the project began.

Then migrants attracted by the project would have services available when they arrived (75). Similarly, to deal with movements of refugees and internally displaced persons, service protocols, training manuals, service delivery guidelines, and informational materials should be prepared in advance and made available as quickly as possible (335).

Rural-to-urban migrants often have poor access to reproductive health care. DHS data suggest that migrant communities are not as well served as other areas. Among contraceptive users, rural-to-urban migrants are more likely than urban nonmigrants to travel an hour or more to reach the nearest source of modern contraceptives (see Figure 6). Having to travel long distances to reach providers discourages use of services (329).

Refugee camps may be located far from hospitals and clinics. When services are unavailable in camps, refugees or internally displaced persons may have to travel many hours to find services in the surrounding communities, if they dare to leave the camps at all (205). In the Great Lakes Region refugee camps, women with complications of pregnancy were referred to district hospitals often 45 minutes to 90 minutes from the camp (222). In contrast, when reproductive health services are available in camps, refugees may have even better access than they did at home (95, 196).

In South Africa projects have provided reproductive health services specifically for temporary migrant workers and their families in mining areas (208). In Azerbaijan mobile teams periodically visit settlements where internally displaced persons are living (117). In Pakistan and China programs have offered nomads unique services, such as audio tapes about reproductive health that women could listen to while herding (124, 254).

Programs also can reach out to refugees living in camps. For example, use of health services often increases when services are located more conveniently (11, 129, 242). In Pakistan, when refugee women were not allowed to leave their homes, health workers went to their homes (333).

Factory-based family planning programs have reached migrants in Mauritius, Thailand, and elsewhere (49, 178, 192, 232, 244). Marie Stopes International has run employment-based reproductive health care projects for refugees and migrants in Bangladesh, Malawi, Madagascar, and elsewhere. They have proved so successful that in some cases employers have begun to help pay their costs (255).

Reproductive health information can reach refugees in camps in a variety of ways. Entertainment activities provide a good setting. In a camp in Thailand, for example, the Thai Population and Development Association showed a popular American movie and, while the reels were being changed, a staff member advised the audience how to obtain family planning. Within several weeks, the percentage of people in the camp using contraception had risen substantially (173).

Good communication is essential for the success of all reproductive health programs (230, 242, 249, 299, 310). Effective communication requires research-based understanding of the audience, including pretesting of messages to ensure that they strike a responsive chord with the intended audience (230). Migrants and refugee groups often constitute a defined audience for communication that responds to their attitudes, interests, and preferences (279).

Mass-media campaigns can be an effective way to provide recently arrived migrants with information about reproductive health services available in their new community. Health messages can be communicated through various mass media, including radio and television, newspapers, billboards, posters, and fliers. Also, community meetings, door-to-door campaigns, seminars, film shows, dances, and street theater can reach people even if their access to the mass media is limited (70, 158, 192, 215, 230, 242).

Interpersonal networks also are a powerful communication channel among refugees, internally displaced persons, and migrant communities (299). These networks can hasten the spread of family planning information by word-of-mouth (97, 157, 230). Messages from reproductive health programs can encourage people to tell their neighbors and family members about services (230).

Based on DHS data in 17 countries, acceptability of family planning messages broadcast on radio appears to be high among both migrants and nonmigrants. In all but one of the countries, however, a slightly lower percentage of rural-to-urban migrants than of native urban residents found family planning messages on radio acceptable. Reflecting their rural roots, migrants may hold more conservative attitudes about reproductive matters and typically have had less experience with family planning and contraceptive use than other urban residents.

Obviously, communication designed for migrants should be in their own language (91, 197). Where most migrants are illiterate, radio broadcasts, videos, or small-group discussions are needed in addition to illustrated pamphlets and other printed materials with few words (35, 46, 70, 172). Contraceptive instructions, too, must be in the clients' language (54).

In developing countries, because rural-to-urban migrants are often poor, and many refugees and internally displaced persons have virtually nothing at all, most people who move cannot afford to pay for reproductive health care themselves (42, 97, 117, 185, 225, 303). In some places private agencies may be able to provide more services (315), while in others, large-scale employers may be able to provide wider insurance coverage or health benefit packages (10). Migrants, however, are among those least likely to have adequate health insurance (34, 241, 326). Refugees and internally displaced persons do not have insurance. For the most part, poor people will always have trouble obtaining adequate services from the private sector and will need to rely on public programs, private voluntary agencies, and international assistance agencies (158).

International assistance agencies have provided substantial support for reproductive health care and have urged that more attention be paid to care for refugees and displaced persons. It is not clear who can provide additional funds, however (25). The UN has urged that at least some reproductive health needs should be met in the emergency phase of refugee situations but that resources should not be diverted from dealing with other priorities (299). Resources available for refugee programs as a whole may be declining, while current reproductive health programs are overburdened (335). Funding for refugee programs needs to become more diversified if reproductive health programs for refugees are to be developed and sustained (279).

To be effective, programs must find out what the people in the community want. Whereas community involvement in health care was once considered politically sensitive and difficult to accomplish, it is widely recognized today that the active participation of community leaders is needed in planning and providing reproductive health care information and services (10, 25, 95, 170, 223, 246, 308, 311, 313, 325, 335, 344). Community participation gives clients a sense of ownership and helps assure that services are acceptable, appropriate, and sustainable (256, 299, 310). In contrast, lack of community support and opposition from community leaders discourages people from using services (158).

Many migrants are resourceful and want to be involved in programs that assist them. In fact, where programs have not sought or acted on community advice and have failed to meet community needs, community-based organizations have sometimes emerged to provide needed services. For example, in poor urban areas of Lima, Peru, lack of social services has spawned a variety of community development efforts, including sex education, under the auspices of Peru Mujer, a national women's organization (192, 204).

Both women and men should be involved. At all levels of planning, carrying out, and monitoring reproductive health care, the participation of women is particularly important (194, 242, 246, 257, 303, 313). Programs should consult with individual women and with women's groups in migrant, refugee, and internally displaced communities (228, 312). In Palestine refugee camps women's groups and networks have increased use of reproductive health services and improved women's well-being (150) (see sidebar, Palestine: Providing Care for Women, by Women).

Because men often are the primary reproductive decision-makers, and their sexual behavior affects not only their own health but also that of their partners and families, men's participation and support are important (170, 318). Among refugees and internally displaced persons, men often express support for reproductive health programs and want to be included, as in camps for internally displaced persons in Azerbaijan. Because of cultural constraints, male health workers conducted training for the men, while female health workers did so for the women (117).

International Efforts for Refugees
     and Internally Displaced Persons

International efforts to provide reproductive health services to refugees and internally displaced persons have greatly strengthened in recent years. In 1997 about 40 agencies operate over 100 such reproductive health projects in 35 countries, according to the United Nations High Commissioner on Refugees (UNHCR), which spearheads efforts to provide reproductive health care for refugees (51) (see sidebar, International Relief Agencies).

UNHCR support for comprehensive primary health care programs in refugee camps now often includes reproductive health services, as in the Caucasus, Ethiopia, Nepal, Rwanda, Sudan, Uganda, and West Africa (53). UNHCR and the International Federation of Red Cross and Red Crescent Societies have provided reproductive health materials and supplies as well as technical assistance to nongovernmental organizations working in Rwanda, Tanzania, Uganda, and the former Zaire.

The United Nations Fund for Population Activities (UNFPA) is not, by definition, a relief agency. Since 1995, however, UNFPA policy has been to assist in providing support for reproductive health services in emergency situations, providing equipment, supplies, and drugs (302). In 1997 UNFPA is supporting reproductive health programs for refugees in more than 40 countries, including Ethiopia, Kenya, Tanzania, Uganda, and Zambia, as well as camps in the Caucasus and Palestine (302).

During the refugee crisis in the Great Lakes region of East Africa that began in 1996, UNFPA supported the International Federation of Red Cross and Red Crescent Societies with a US$500,000 emergency grant, providing refugees with contraception, delivery kits, and condoms to help protect against HIV (119, 134). This project was the first time that reproductive health services have been included at the beginning of a refugee emergency (301).

UNFPA gives high priority to the needs of adolescents (54). Among refugees living in camps, schooling is rarely available above the primary level; adolescents have little to do, and frequent sexual activity is one result (222). Often separated from their parents and other family members (54), refugee and internally displaced adolescents are particularly powerless and thus subject to abuse (287). UNFPA is developing a program in central Africa to address reproductive and other health needs of adolescents returning from refugee situations (302).

The International Rescue Committee (IRC) provides reproductive health services to refugees in nine countries (12). In 1992 IRC started two pilot projects to deal with the needs of Liberian refugee women in Côte d'Ivoire and Ghana (117, 118). IRC provides family planning education, contraceptive supplies, and transportation so that women can reach providers who insert IUDs or give injections (119).

The International Planned Parenthood Federation (IPPF) and its affiliates are involved in many refugee projects. For example, the Arab World Regional Office (AWRO) of IPPF, with UNFPA support, is providing clinic and community-based reproductive health services around the port city of Bosaso in northeast Somalia. Most of the original 120,000 residents had fled to other parts of the country during the long civil war, but recently they returned (54). Also, the Ivorian Association for Family Well-Being (AIBEF), an IPPF affiliate, has launched a project to improve access to reproductive health services among Liberian refugees who have settled in the west and southwest parts of Côte d'Ivoire (38, 260). IPPF's Rokhana Kor project in Peshawar, Pakistan, has provided reproductive health services to Afghan refugees since 1989. Other refugee areas in which IPPF provides services include Bosnia and Herzegovina, Guinea, Palestine, Sierra Leone, and Tanzania (54).

CARE has provided reproductive health services to refugees living in camps in Rwanda, within a maternal and child health program designed for internally displaced persons. This is the only reported instance of extending services initially intended for internally displaced persons to serve refugees as well (335).

In an emergency, providing food, shelter, clothing, safety, and sanitation are first priorities for relief agencies. Only when these needs are met do they address other issues such as STDs, contraception, and other reproductive health needs (253). The United Nations states that priorities in an emergency situation are shelter, protection against abuse and violence, safe drinking water and food, and basic health services. Basic health services are now understood to include reproductive health care (302). To date, however, only a few emergency responses have done so (125, 202, 335).

The development of the Minimum Initial Service Package (MISP) for the emergency phase of a refugee situation was an important outcome of the Inter-Agency Symposium on Reproductive Health in Refugee Situations, held in 1995 (see sidebar, International Relief Agencies). Originally developed and used by Marie Stopes International, the MISP focuses on reproductive health care that saves lives and thus establishes common ground between traditional emergency care and reproductive health care (278). The Reproductive Health for Refugees Consortium is working to have MISP provided as part of the emergency phase of all relief efforts (189).

The MISP contains a mix of essential information, services, and commodities for reproductive health care, including delivery kits for use by refugee women themselves, midwife kits from the United Nations Children's Fund (UNICEF), condoms, and guidelines on enforcement of universal blood precautions to prevent the spread of HIV/AIDS and other blood-borne diseases and on prevention of sexual violence and management of its consequences, such as offering emergency oral contraception (a regimen of combined oral contraceptives taken after unprotected sexual intercourse). The MISP also calls for a reproductive health coordinator in each refugee camp (119, 129, 242, 280, 299). To make the MISP effective, refugee relief workers require training, because many know little about reproductive health care (222).

Once the emergency phase ends, refugee service providers should examine the broad range of reproductive health needs of refugees and displaced persons, including needs for prenatal, delivery, and postnatal services, STD prevention and treatment and HIV prevention, and family planning counseling and services (119). While the MISP will improve emergency responses, a longer-term solution requires providing reproductive health care as part of any health package. For example, a field manual under development by the Reproductive Health for Refugees Consortium (see sidebar, International Relief Agencies) recommends that reproductive health services be combined with other primary health care for refugees (299).

Agencies can jointly plan and deliver services, as did Marie Stopes International and the World Health Organization (WHO) in 1993 in providing reproductive health kits for refugees in Bosnia (255). Similarly, in 1995 the International Rescue Committee (IRC) and UNHCR together provided reproductive health services in a camp in Tanzania for refugees from Rwanda (78).

Still, there is substantial international concern about the plight of internally displaced persons and their reproductive health care needs. The United Nations recently created the post of Representative of the Secretary-General on Internally Displaced Persons to play a coordinating role in relief activities for internally displaced groups (93). While the mandate of UNHCR does not cover internally displaced persons, it has assumed limited responsibility for them (73, 297).

A number of agencies provide reproductive health care to internally displaced persons, including the UK Department for International Development (formerly the Office of Development Assistance), the World Food Program, the United Nations Children's Fund (UNICEF), the United Nations Development Program (UNDP), and the Office of Foreign Disaster Assistance (OFDA) of the US Agency for International Development (USAID) (55, 93, 335). Other relief or assistance agencies also have provided reproductive health care to internally displaced persons—as many as 20 in 12 countries, including the International Committee of the Red Cross (ICRC), Médecins sans frontières, and Deutsche Gesellschaft Technische Zusammenarbeit (GTZ) (51).

Given their large numbers, rural-to-urban migrants are becoming an important new focus for urban reproductive health programs. Many programs have much to learn about how to serve these new clients better. Despite a growing number of program activities for refugees and internally displaced persons, they still often lack sufficient access to good reproductive health care. To serve them better, programs need to allocate more resources, learn more about these new clients, communicate better with them, and reach out to them with services.

Sidebars

Comparing Migrants, Refugees, and Internally Displaced Persons

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).

Understanding DHS Data on Migrants

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.macroint.com/dhs/getdata.html).

Research Needs for Planning Services

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.

Palestine: Providing Care for Women, by Women

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."

International Relief Agencies

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.

Figures

Tables

Table 1.
Largest Refugee Populations, 1995 (in 1,000s)

By Country of Origin	Population (in 1,000s)		By Country of Asylum	Population (in 1,000s)
Palistine	3,286		Iran	2,075
Afghanistan	2,328		Zaire	1,332
Rwanda	1,545		Jordan	1,294
Boznia/Herzogovina	905		Pakistan	867
Liberia	725		Tanzania	703
Iraq	623		Guinea	640
Somalia	480		Gaza Strip	684
Sudan	448		West Bank	517
Azerbaijan	390		Russia	500
Sierra Leone	363		Sudan	450
Eritrea	342		Yugoslavia	450
Angola	313		Germany	443
Vietnam	295		Lebanon	48
Burundi	290		Syria	342
Croatia	200		India	319
Armenia	185		Ethiopia	308
Tajikistan	170		Armenia	304
Myanmar	160		China	294
China (Tibet)	141		Côte d'Ivoire	290
Bhutan	119		Azerbaijan	238
Ethiopia	111		Uganda	230
Georgia	105		Kenya	225
Mozambique	97		Croatia	189
Other former Soviet Union	97		United States	152
Western Sahara	80		Nepal	106
Other countries	1,178		Other countries	1,537
Total	15,337		Total	15,337

Source: US Committee for Rufugees (321)