Socio-Cultural Influences On The Reproductive Health of Migrant Women (A Review of Literature in Lao PDR)

SOCIO-CULTURAL INFLUENCES on the reproductive health of migrant women
A REVIEW OF LITERATURE IN LAO PDR
Cover Photo: Thomas Wanhoff Design and Layout: Philip Nalangan, UNFPA APRO Published in March 2012 The views expressed in this document are solely those of the authors, and do not necessarily reflect the official views of the United Nations Population Fund or the United Nations.
SOCIO-CULTURAL INFLUENCES on the reproductive health of migrant women

A REVIEW OF LITERATURE IN LAO PDR
Table of Contents
Acknowledgements ........................................................................ iii Foreword .......................................................................................... iv Executive Summary ....................................................................... vi Acronyms ......................................................................................... xi 1. Introduction .................................................................. 1.1 Review methodology ............................................................. 2. 2.1 2.2 2.3 2.4 2.5 2.6 3. 3.1 3.2 3.3 3.4 3.5 3.6 3.7 1 1
Background .................................................................. 3 Internal migration trends ....................................................... 3 Policy environment .................................................................. 6 Existing reproductive health information and services .... 9 Profi le of female migrants ...................................................... 12 Migrant women occupations ................................................. 13 Programmes targeting internal migrants ............................. 18 Review Findings .......................................................... Education and social change ............................................... Migrant networks .................................................................... Ethnicity ..................................................................................... Gender ........................................................................................ Health-seeking behaviour ..................................................... Health service provider attitudes ........................................ Return and reintegration ....................................................... 21 21 22 24 28 33 35 35
4. Strengths and Gaps ................................................... 37 4.1 Research .................................................................................... 37 4.2 Programme gaps and possibilities for replication ......... 38 5. Conclusions and Recommendations ......................... 41 Endnotes .................................................................................... 47 People Interviewed ................................................................. 58 Overview from four Mekong country reviews .................... 59
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Acknowledgements
This publication has been prepared by the UNFPA Asia Pacific Regional Office (APRO) in collaboration with the UNFPA Lao PDR Country Office. The review was initiated by the UNFPA Technical Division, New York, with funds from the Gender, Human Rights and Culture branch, and guidance from Azza Karam, Senior Socio-cultural Adviser. Thanks are extended to Maria Holtsberg who conducted the literature review and prepared the first draft of the report. With inputs from Theresa Devasahayam, Coordinator, Gender Studies Programme, Institute of Southeast Asian Studies Singapore, and Karen Emmons, Editor, the report was finalized by Anne Harmer, APRO Socio-cultural Adviser. Pafoualee Leechuefoung, Assistant Representative and T.A. Garraghan, Consultant, from the UNFPA Lao PDR office provided valuable comments and insights to the review. Acknowledgement is made of the representatives of the Lao PDR-based organisations that contributed materials and inputs for the review including: Acting for Women in Distressing Circumstances, Burnett Institute, CARE, Family Health International, Friends International, International Office of Migration, Lao PDR Gender and Development Group, Norwegian Church Aid, Population Services International, Save the Children, United Nations Children Fund, United Nations Development Fund for Women, and the United Nations Inter-agency Project on Human Trafficking; and to the following individuals who also provided materials and inputs: Jim Chamberlain, Mariolien Coren, Serge Doussantousse, Chris Lyttleton and Vonemaly Mongnomek. Finally, thanks must also be given to Mieko Yabuta, UNFPA Representative of Lao PDR, who recognised the potential of the study for the broader work of the UNFPA in Lao PDR.
SOCIO-CULTURAL INFLUENCES ON THE REPRODUCTIVE HEALTH OF MIGRANT WOMEN
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Foreword
Since the early 1990s internal migration has been gradually increasing in Lao PDR. This results from a number of factors, including government resettlement policies, the development of transport infrastructure and road systems, as well as individuals desire to seek alternatives to poverty. A concern regarding migrants in Asia is with respect to the neglect of their rights, including rights to access reproductive health information and services. Barriers to accessing services are frequently institutional, exposing migrants to greater risk of illness than non-migrant people and often excluding them from formal medical systems. At the same time, socio-cultural factors play a part in influencing the behaviour of migrant women, including their decisions on when and whether to access health care. To gain a better understanding of the links between sociocultural factors and the reproductive health of migrant women, UNFPA Asia Pacific Regional Office commissioned literature reviews in four Mekong sub-region countries Cambodia, Lao PDR, Thailand and Viet Nam. This report documents the findings of the Lao PDR review and makes recommendations on how policy makers, employers and service providers could better address the reproductive health needs of migrant women. For many women, moving to another part of the country is disruptive. Lack of familiarity with new locations, less access to traditional support systems, exposure to different lifestyles and influences, and vulnerability to exploitation and abuse are some of the factors that impact on migrant womens health. Social and cultural norms in the Lao PDR, along with traditional values and beliefs, impact on womens decision making and health seeking behaviour.
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FOREWORD
The report highlights some of the challenges migrant women face in trying to access reproductive health information and services, and suggests ways in which policy and service provision might be improved to meet their needs. A holistic approach that addresses the full range migrant womens needs, and which empowers them to claim their own rights to reproductive health, is essential. These elements are at the heart of the Programme of Action of the International Conference on Population and Development (ICPD), and central to the work of UNFPA. If realized, these rights would also contribute to the attainment of the Millennium Development Goals, particularly MDG 5, and also MDGs 3 and 6. I hope that the findings of the review will be useful in informing future policy and service provision.
Dr. Esther Muia UNFPA Representative in the Lao PDR
Executive Summary
The United Nations Population Fund (UNFPA) commissioned a review of literature regarding the socio-cultural influences on the sexual and reproductive health of internal female migrants in Lao Peoples Democratic Republic (PDR). It is one in a series of four reviews of the situation in Mekong countries. As the research turned up very little literature focusing on the specific theme of the review, related documents that may have some correlation were reviewed and analysed. Based on findings from the range of materials reviewed, this report describes perceived trends and unmet needs, and outlines how further research could inform strategies to improve reproductive health service provision for female migrants.
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EXECUTIVE SUMMARY
William A. Ryan / UNFPA APRO
Migration in Lao PDR Lao PDR is a landlocked country with Cambodia, China, Myanmar, Thailand and Viet Nam as its neighbours. Its geographic location creates favourable conditions for trade, tourism and communication, and a road system was recently constructed that links the Mekong countries. Lao PDR has become the hub for land transportation for the entire region, with new highways in the northern provinces linking China, Myanmar and Thailand and in the southern provinces linking Cambodia, Thailand and Viet Nam. Although still a Communist country, the Government of Lao PDR adopted in 1986 a policy of economic development based on a modernized, marketoriented system, that has led to the establishment of economic corridors with improved infrastructure. These developments have contributed to social and cultural change for communities in affected areas, and have increased rural peoples movement to locations within newly established economic zones and factories. Between 1995 and 2005, the urban population in Lao PDR increased from 17 to 27 per cent. The capital, Vientiane, is a major destination for migrants from the northern provinces, while residents in the southern provinces have tended to migrate across the border into Thailand. There have also been increasing levels of internal migration to provincial capitals and medium-sized cities. North-north migration is taking place to emerging economic zones and along the economic corridors. With new infrastructure developments taking place in the South, a similar migration pattern is likely to follow. According to the available literature, although more males migrate than females, increasing numbers of young women are moving to urban areas in search of employment. In 2006, some 74 per cent of the migrating population were aged 18-35. Reported evidence has suggested that those who migrate are not the poorest of the poor or the least educated. Women migrants from ethnic groups, for example, have usually acquired Lao language skills, which indicates they have had some level of education. It is unclear from the literature reviewed how many internal migrants have returned to their places
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of origin and if their health-seeking behaviour had changed or was affected by their migration experience. A combination of push and pull factors shape the decision to migrate. The push factors reported included unemployment or poverty, the need to financially support family, and a change in agricultural practices that has made farming less economically sustainable. Reported pull factors included employment opportunities and higher wages in urban areas. Among young people, migration is perceived almost as a rite of passage or an opportunity for a more modern lifestyle. Women who leave their communities do so with the expectation of improving their own quality of life, as well as that of their families. Review findings The reviewed literature indicated that young women who have migrated have most commonly been employed as domestic or factory workers, with others seeking employment in the service industry, such as working in beer bars. No literature was identified that specifically described the situation of migrant domestic workers. Whilst the majority of migrant women are unlikely to have engaged in transactional sex or in sex work, most of the literature identified focused on the minority that have engaged in such activities. This resulted in a somewhat skewed representation of migrant women that appears to be also reflected in the national response to their reproductive health needs: namely a focus on their sexual behaviour, and prevention of STI and HIV transmission. Migrant women are considered vulnerable to various types of exploitation due to their young age and challenging working conditions, including in factories. Factory workers tend to live in dormitories and although their movement is frequently restricted by their employers, they still seek out partnerships and sometimes engage in risky behaviour. Women working in factories may not have the skills to negotiate condom use. According to one of the reviewed documents, an estimated 4,000 service women were engaged in some type of sex work in Lao PDR in 2008, although not all would necessarily self-identify as a sex worker. Female migrant workers in beer bars or entertainment complexes are paid for drinking and providing companionship to male customers, and sometimes have sex with clients.
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EXECUTIVE SUMMARY
Women who have identified as sex workers cited better financial rewards as their motivation for engaging in this work. The reviewed documents noted that condom awareness, as well as condom use with clients, has been fairly high among sex workers, particularly in comparison with female factory workers. However, few of them reported using condoms with their regular partners, who are more commonly perceived as boyfriends. Women used condoms with clients but may have been pressured by boyfriends to not use them; some believed that because of professed love between them, they were safe from sexually transmitted infections, including HIV. An increasing number of women from ethnic groups have been migrating to urban centres or to rural locations where there are employment opportunities. Lao PDR has 49 recognized ethnic groups, divided into four major ethnolinguistic groups. Some groups were more predominantly represented among surveyed migrants, such as the Thai Deng and Khmu. There were cited examples in which traditional sexual practices of an ethnic group appeared to increase migrant womens risk behaviours. Ethnic migrant women were regarded as less likely to treat a sexually transmitted infection (STI) because they may not seek out reproductive health services. Migration is facilitated by different forms of networks. In some cases, according to the available literature, family and community members organized a young womans migration journey, thereby maintaining control over her while also providing protective security. Migration can also be mediated by contacts, or facilitated by bar owners who travel to rural areas to find workers. In those cases, female migrants have joined a new social network in their destination locale. Either way, an established network of support has the potential to be an enabling factor for reproductive health information and services for some migrants, although evidence of this was not found in the reviewed literature. Unfortunately, very limited information on where and how internal migrants seek reproductive health information and services was identified through the review. The available research indicated numerous likely barriers to accessing reproductive health information and services. Working conditions can be a major barrier: factory workers usually live in small dormitories in the workplace without any privacy and with restricted freedom of movement. Long working hours also prevent visits to health care facilities. Other likely barriers include fear of authorities, inconvenient operating hours of facilities, discrimination by health service providers, and the limited range and coverage of health and
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social insurance schemes. Due to their illegal status, sex workers in particular may fear seeking health care from government services. The main reproductive health needs of internal migrants drawn from the literature review include access to contraception, safe abortion, post-abortion care and STI testing and treatment. Reproductive health care seems to have been typically sought through over-the-counter remedies in pharmacies and from private clinics. No examples were identified of project interventions specifically targeting internal migrants, suggesting that this group has been overlooked. It can be surmised however that some internal migrants probably benefit from programmes that target general populations. For instance, there are a number of projects that directly target sex workers, factory workers or urban populations. All these groups include internal migrants. Conclusions The review found a general lack of literature that described the full journey of migration, or the reproductive and sexual health concerns of internal migrants. There was an absence of references to a broad range of aspects of reproductive health. For instance, no reference was found related to maternal health practices among migrant women. Most of the reviewed literature related to migrants and health focused only on STIs and HIV. The paper concludes with recommendations for in-depth qualitative and quantitative research on the situation of internal migrants in Lao PDR. If available, research on who the migrant women are, where they come from, and why they choose to migrate, could provide vital information for policy makers and development practitioners that could be used to ensure that services are provided, and that womens reproductive rights are protected. Other recommendations include advocating to policy makers to address the legal status of internal migrants and to ensure inclusion in health insurance for those in formal employment, as well as in less-structured employment. Building up the capacity of health care providers to offer client-friendly services, especially for unmarried women and specific groups such as sex workers and factory workers, are important steps towards improving internal migrants access to reproductive health information and services.
EXECUTIVE SUMMARY
Acronyms
AIDS CBHI FHI GTZ HIV IEC IOM NCA NGO PSI RCN SSO STI UNICEF UNFPA UNIAP VCT WHO Acquired Immune Deficiency Syndrome Community-Based Health Insurance Family Health International German Agency for Technical Cooperation Human Immunodeficiency Virus Information, Education and Communication International Organization for Migration Norwegian Church Aid Non-Governmental Organization Population Services International Referral and Counselling Network Social Security Organization Sexually Transmitted Infection United Nations Childrens Fund United Nations Population Fund United Nations Inter-Agency Project on Human Trafficking Voluntary Counselling and Testing World Health Organization
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CHAPTER ONE
Introduction
1.1 Review methodology The United Nations Population Fund (UNFPA) commissioned a review of available literature on how socio-cultural factors affect the sexual and reproductive health of internal female migrants in the Lao PDR. It is one in a series of reviews of the situation in four Mekong countries (see the annex for an overview summary of the findings from all four countries, which also covers Cambodia, Thailand and Viet Nam). The objective of the literature search was to identify and highlight socio-cultural influences on migrant womens health-seeking behaviour, in order to explore how further examination of these influences could be used to inform strategies to improve service provision for this group. Additionally, the research sought to identify the enabling factors and barriers to accessing reproductive health information and services. However, the initial search of materials, dating back over the past ten years, turned up very limited information relating specifically to the sexual and reproductive health situation of internal migrants, and even fewer references to related socio-cultural influences. In the absence of literature specifically relating to sexual and reproductive health and related socio-cultural aspects of migration, materials were reviewed that addressed internal migration in general, trafficking, ethnic groups, reproductive health, and HIV, to obtain as broad an overview as possible. Documents relating to the situation of factory workers, women working in the service industry (bars and other entertainment venues) and sex workers were reviewed, recognizing that these are the main choices available to women who migrate in Lao PDR. Literature on ethnic groups was also reviewed, providing a picture of the situation in
certain communities of origin, where many of the female migrants may have come from and sometimes plan to return to. An attempt was made to examine relevant research in known provinces of origin and in destinations to provide as comprehensive a picture as possible. However, the lack of material describing the migration journey, outlining different steps along the way and describing the sexual and reproductive health concerns and health-seeking behaviour of migrants considerably constrained the scope of the review. Based on the available literature pertaining to rural and urban women and the movement trends of internal female migrants, this paper thus largely presents assumptions about the situation of female migrants and their reproductive health needs. Most of the documents reviewed were reports and qualitative studies commissioned by development organizations, including United Nations agencies, the Asian Development Bank (ADB) and NGOs. Studies conducted by independent researchers and relevant Government reports were also reviewed. Informal interviews were conducted with relevant staff from United Nations agencies, including UNFPA, UNIFEM1, the United Nations Inter-Agency Project on Trafficking (UNIAP) and the International Organization for Migration (IOM); and with NGOs, including Population Services International (PSI), Acting for Women in Distressing Situations (ASEFIP), CARE International, the Gender and Development Group, Norwegian Church Aid (NCA), the Burnet Institute and Friends International. The purpose of the interviews was to identify relevant materials for review, to seek additional information on available sources, and to learn about relevant areas of programming that target migrant women. It transpired that most of the organizations the consultant met with do not specifically target internal migrants, although their target populations may include them. Meetings and correspondence also took place with independent researchers. This paper contains a number of speculative assumptions that are put forward as likely socio-cultural influences on sexual and reproductive health choices and outcomes, based on the available, albeit limited, literature on rural Lao women, ethnic women and migrant women. Without such triangulation it would have been difficult to identify sufficient relevant information on the topic. Where such assumptions are made, they are acknowledged in the text.
CHAPTER ONE: INTRODUCTION
CHAPTER TWO
Background
2.1 Internal migration trends Lao PDR is a landlocked country with a population of 5.6 million people and 49 recognized ethnic groups that are divided into four major ethno-linguistic groups. Some 52 per cent of the population belong to the ethnic Lao Loum group, while the rest is divided among the other groups. The geographic location of Lao PDR, with Cambodia, China, Myanmar, Thailand and Viet Nam as its neighbours, creates favourable conditions for trade, tourism and communication. Lao PDR is strategically placed to provide services and communication and has become the hub for land transportation for the entire region, especially the northern part of the Mekong region. Road systems were recently constructed that link China, Myanmar, Thailand and Viet Nam.
Since the early 1990s, internal migration has been gradually increasing in Lao PDR due to a variety of factors including government resettlement policies, the development of transport infrastructure and road systems, as well as individuals desire to seek alternatives to poverty and isolation. There are local variations within the country, not only in the incidence of migration but also in terms of destinations, types of work at destinations, organization of migration, composition of migrants and the effects of migration on the origin communities.2 Although still a Communist country, in 1986 the Government of Lao PDR adopted a policy of economic development based on a modernized, marketoriented system, that has led to the establishment of economic corridors with improved roads and infrastructure. These developments have contributed to social and cultural change for the communities in those areas, and have increased rural peoples movement to areas with newly established economic zones and factories. Many sectors, such as wood processing, textiles and garment production, have expanded, attracting people from around the country to the employment opportunities they provide.3 Between 1995 and 2005, the urban population in Lao PDR increased from 17 to 27 per cent as a result of internal migration, although there are differences in the migration paths between the northern and southern regions.4 In the north, internal migration has been rather high in many provinces, whereas it has been lower in the southern provinces, apart from cross border migration to Thailand. Vientiane is a major destination for migration from the northern provinces. Areas with low levels of outmigration to Vientiane seem to have high levels of outmigration to other countries, especially to Thailand. In addition, there have been high levels of rural-to-urban migration to provincial capitals and medium-sized cities.5 Analysis from the 1995 and 2005 censuses shows that, among migrants, the percentage of never married males and never married females was 51.7 and 47.2 respectively, indicating that slightly more males than females migrated over that period of time. Among both males and females, those who had never married were more likely to move. The proportion of the younger population among both migrant males and females was more than among their resident counterparts: of migrant males aged 15-24 and 25-49, the percentages were 38.5 and 42.8, compared with 27.4 and 38.4 among residents. Among migrant females, the proportion of those aged 15-24 and
CHAPTER TWO: BACKGROUND
25-49 was 46.1 and 33.5, compared to the corresponding proportions of 27.1 and 39.0 for resident females in the corresponding age groups.6 This indicates that a high number of young women choose to migrate. The Governments social policies, especially those related to agriculture and resettlement, have been another push factor. The policy on restriction of land use for swidden agriculture/shifting cultivation has led to shorter fallows, at present three to four years compared with eight to ten years. This has led to a more difficult agricultural process,7 resulting in food insecurity, especially in rural and ethnic communities, which have a particularly harsh impact on women because of the central role they play in food collection and management.8 Families are therefore inclined to seek alternative opportunities to raise income. As part of its economic development plan and other policies, the Government promoted resettlement schemes within rural areas, and these have also impacted on migration patterns. Internal resettlement programmes serve an important function in terms of bringing poorly visible rural populations, often ethnic groups, into the view and reach of the State.9 This is one of the ways the Government has chosen to address regional inequalities, as poverty is mainly concentrated in the upland areas inhabited by ethnic groups. The policy of relocation was intended to consolidate disbursed villages to improve service delivery to the rural population and to stabilize shifting cultivation, eradicate opium production, (and) extend administrative control by consolidating villages into larger villages to foster the cultural integration of ethnic groups into Lao society.10 In reference to the shift in residence from highland to lowland areas among the Akha of Muang Sing and Muang Long districts in Luang Namtha province, Lyttleton has argued that even though the geographical distance moved may have been only up to 20 kilometres, the transformation associated with moving justifies the term migration relevant in their case: a two-day walk on difficult paths takes the Akha away from forests, away from subsistence and away from lifestyles based primarily on local exchange to the embrace of lowland values based on market enterprise, consumerism and wage labour.11 Driven sometimes by state pressure and sometimes by their own decisions to relocate closer to roads and markets, the lives of many ethnic groups, have experienced rapid social change.12
In more recent times, the patterns of migration have shifted, especially in the northern provinces, as north-north migration has increased to the emerging economic zones and along the economic corridors. Similar changes can be expected in the South due to infrastructure development currently taking place. Large-scale mining, construction and dam projects have resulted in increased migration to those locations.13 Both push and pull factors influence more recent decisions to migrate. Push factors cited in the reviewed research referred to the conditions in the communities of origin, such as poverty, unemployment, personal misfortune and the hardship of rural life. Pull factors included employment prospects, greater income and the attraction of the city dynamic.14 An ADB-commissioned report detailing lessons learned from development of the northern economic corridor described how the opening up of previously remote areas had resulted in networks reaching far beyond directly affected local communities, to remote villages that have been drawn into the orbit of newly constructed roads. A new trade and investment zone - Boten Golden City - provides an example of the way in which widely disparate groups of people came together in a place that became a attraction for those with money, and those hoping to make money. The casino located there attracted thousands of Chinese visitors per week, was staffed by young Lao men and women from around the country and also drew ethnic people seeking opportunities within the market economy.15 2.2 Policy environment Legal status The Lao PDR Government has instituted policies to either keep people in place, or to move them through resettlement schemes, although the reviewed literature revealed limited information concerning the legal status of internal migrants. Most Government efforts have emphasized regularizing and controlling cross-border migration, mainly to Thailand. Since 2002, Lao PDR and Thailand have had a bilateral agreement to regulate labour migration to Thailand.16 In contrast, internal migration, whilst widespread and also sensitive, is, in Lao PDR, only just beginning to attract some attention from a policy perspective.17 Any movements are regulated by village heads or other authorities, although the reviewed sources did not describe how the regulation is implemented.
Some internal migrants end up involved in sex work or, as it is termed locally, service work. The Lao Penal Law describes sex work as a criminal offence in Chapter 6: Breach of Marital and Family Relationships and of Customs, under Article 131 concerning prostitution, with penalties ranging from short prison sentences, to re-education and relatively small fines. Generating an income from sex work or forcing women or girls into sex work is also prohibited under Articles 132 and 133 of the Penal Law.18 National policies The National Population and Development Policy (NPDP) of the Government of the Lao PDR (adopted through a 1999 Government Resolution, and updated in 2006) provides a broad framework to address population and development issues in the country, and includes a commitment to improving the quality of life of all citizens through the nationwide provision of primary health care, reproductive health and family planning services.19 The 2005 National Reproductive Health Policy provides guidance for achieving the policy goals outlined in the NPDP and other existing policy instruments congruent with the National Growth and Poverty Eradication Strategy, such as the National Policy on Birth Spacing (1995), Policies on Maternal and Child Health Particularly Safe Motherhood in Lao PDR (2002), the National Policy and Strategy for the Prevention and Care of STD (1998), the National AIDS Policy for Lao PDR (2001) and the Health Strategy 2020.20 In addition to recognizing that access to health services is particularly difficult for women, ethnic groups, poor people and those with low levels of education, the National Reproductive Health Policy also acknowledges that high migration and urbanization rates are exacerbating local planning deficiencies and placing stress on fragile urban infrastructures. The vulnerability of migrant workers to HIV infection is specifically recognised in the Lao PDR National Strategy and Action Plan on HIV/AIDS/ STI 2006-2010, which include strategies to address the specific needs of migrant populations and their families, focusing on both external and internal migrants. Identified strategies include: i) increasing the understanding of contextual factors and risk behaviour that contribute to the vulnerability of mobile populations and their families through studies and surveillance; ii) reducing the vulnerability of mobile populations and their families to STIs and HIV/AIDS through awareness raising campaigns, training and behaviour change interventions; iii) expanding services, including social marketing of
condoms, confidential STI services, voluntary counseling and testing and referral systems, and advocating for the legal protection of migrants; and iv) increasing responsiveness to the needs of migrants and their families through integration of prevention activities into infrastructure projects, plus a range of activities targeting cross border migration.21 Health insurance Although internal migrants on contracts of more than three months are expected to subscribe to the compulsory health insurance scheme of the Social Security Organization (SSO), many workers have not complied with this requirement. The geographical spread of the SSO is also limited, covering only the capital and selected major urban areas, such as Luang Prabang and Savannakhet. Internal migrants who work in the informal sector (such as domestic workers, casual labourers, farm workers) are entitled to enrol in the voluntary Community-Based Health Insurance (CBHI) scheme. However, initiated in 2006, the CBHI has only started to function in about 20 of the countrys 144 districts, although there is a plan to roll out the system with a targeted coverage of 27 per cent of the population by 2015.22 Under this scheme, the whole family of a migrant worker will be eligible for enrolment.
UNFPA Lao PDR
The SSO and the CBHI schemes cover maternal and child health, as well as STI treatment and reproductive health services, with no extra payment at the time of use. However, maternal and child health services for all Lao citizens in any health facilities are reportedly almost free of charge, with only a nominal fee for a mother-and-child health (MCH) record booklet, and consumables such as contraception. All MCH examinations and consultations are reportedly free. Antibiotics for STIs are not free unless provided by an externally funded STI programme, supported, for example, by a NGO. All consumables and drugs must be paid for in cases of obstetric care.23 None of the three formal health insurance schemes - the civil servant health insurance, the SSO and the CBHI - have yet reached the most poor.24 2.3 Existing reproductive health information and services Sexuality education The Ministry of Education, UNICEF, UNFPA and the German Agency for Technical Cooperation (GTZ) developed a standard set of curriculum materials based on the life skills approach that covers population education, reproductive and sexuality education, healthy living, and HIV and drug abuse prevention. The curriculum has been incorporated from primary school level upwards, reaching 15 per cent of primary schools and 80 per cent of secondary schools in 11 provinces (out of a total of 17) as of 2008, thus targeting in-school youth. A pre-service curriculum for teachers was developed and incorporated into eight teacher training colleges, including Luang Namtha, Luang Prabang and Xiengkouang, which are provinces that experience a significant volume of internal outmigration.25 In 2009, a total of 855 schools provided life skills education. However, a UNICEF-supported assessment in 2010 revealed that the education system had not yet fully embraced the life skills approach because the changes came too quickly in a system already burdened by reform; teachers were unable to meet the rapidly changing needs of a new generation of students.26 The project evaluation did however reveal a greater awareness among students of protective measures, such as 92 per cent awareness of condoms compared with 74 per cent in 2006.27 The evaluation covered six provinces, of which Udomxay and Luang Namtha were provinces with large outmigration flows at the time. The report does not present any specificities related to the various provinces. It is thus not possible to determine the effectiveness of the life skills education received by students living in those provinces.
That said, if internal migrants from these provinces completed grade 8 and grade 11, it could be assumed that they received some form of sexuality education through the life skills approach. However, given the limitations in the execution of the curriculum, including teachers not yet skilled in either the life skills approach or knowledgeable about the content, and with the focus being mainly on biological facts, it cannot be assumed that participation in such a course will have provided girls and young women with the necessary information and skills to protect themselves from sexual and reproductive health-related risks, particularly for those who might place themselves at greater risk through migration. Primary health care and sexual and reproductive health services The Ministry of Public Health has overall responsibility for delivering health services throughout the country, with Provincial Health Offices having administrative responsibility for provision of services through provincial and district hospitals, health centres and other facilities. Health centres and village health volunteers refer patients to the district hospitals; district hospitals refer to the provincial hospitals; and provincial hospitals refer to the regional or central hospitals. These services are sometimes supplemented by mobile services, staffed by district health personnel.28 An ADB grant proposal noted in 2007 that the use of public health care services was generally low, especially at district hospitals and health centres. Of those seeking treatment, 26 per cent used a village health volunteer or village health provider; 40 per cent went to a government facility; and 29 per cent relied on a private pharmacy or clinic.29 A 2001 review of the countrys primary health care system suggested that the absence of regularly assigned staff and irregular opening hours limited the use of clinics. The report cited examples of culturally inappropriate services that limited ethnic groups use of health services. The lack of trained health staff from within ethnic groups, for instance, indicated that it was unlikely services were provided in local languages or used culturally acceptable approaches. Thus, people preferred to buy over-the-counter drugs or to consult private and traditional practitioners rather than use public health services.30 A 2000 World Health Organization (WHO) assessment of reproductive health care found more than 900 private clinics, most of which were located in Vientiane, and almost 2,000 registered pharmacies, located mostly in urban areas in close proximity to district or provincial hospitals.31
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In terms of maternal health care, the WHO assessment also found that a large number of the 126 district hospitals had very limited resources, equipment and drugs to provide adequate service.32 Anecdotal evidence suggested that induced abortion was common among both married and unmarried women. Many of the women in the assessment sought out abortions in private clinics (often across the border in Thailand) or from unqualified providers. Abortions were typically performed under unsafe and unhygienic circumstances, and thus complications were very likely. In terms of treatment for reproductive tract infections, practices for treating common symptoms were not standardized or applied in a systematic way.33 Based on the available evidence, it is most likely that the consistency and quality of routine services varies across the country. Limited accessibility to services seemed to be a major issue, with the district hospital only being approached for antenatal care and childbirth delivery if located nearby, according to a 2005 study of gender and ethnicity, which noted, Home deliveries are the norm for rural Laos as well as for ethnic women. Ethnic women are more likely to have a delivery by untrained attendants.34 Describing newly available reproductive health services targeting the Akha in Muang Sing and Muang Long districts of Luang Namtha province, Lyttleton and Sayanouso acknowledged that while assisted deliveries and even birth spacing might be welcomed, the promotion of smaller family size has been of less interest to the Akha, among whom infertility has been high. The very high rates of STIs, which could account for the high infertility, had not been addressed at all by the local health services.35 According to the 2004 Household Survey, 53 per cent of villagers in the eight northern provinces lived within one hour walking distance from a hospital or health centre, and 16 per cent lived more than four hours away. Physical access is becoming less of a barrier to health services for most people. However, physical and social access is still poor for women needing reproductive health care and for remote ethnic communities in general.36 The 2005 National Reproductive Health Survey reflects that gradual improvements have been made in key health indicators since a similar survey was undertaken in 2000. This implies an improvement in service delivery, as well as increased uptake of services. For example, contraceptive prevalence rate among married women using modern methods increased from 28.9 per
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cent in 2000 to 35 per cent in 2005; the percentage of deliveries attended by doctors or midwives increased from 9.8 per cent to 11.1 per cent over the same period; and the number of women who had ever heard of HIV increased from 69.3 per cent to 70.4 per cent.37 2.4 Profile of female migrants According to the reviewed literature, young women have represented the largest group of migrants. Nearly three-quarters of those cited in a 2010 ethnographic study left home when they were still single (never married).38 In 2006, young people (18-35 years) made up an estimated 74 per cent of the migrating population (data was not disaggregated by sex). In the population age group of 10-17 years, there were significantly more girls migrating than boys, with girls more vulnerable to the risks of trafficking and labour exploitation.39 The need and desire to seek better economic opportunities for themselves and their families was the main reason young women respondents gave for choosing to migrate. However, according to findings from the reviewed literature, women who have migrated have not been the poorest of the poor, nor the least educated. Female migrants have come from different ethnic groups and localities and have migrated along paths facilitated by kinship or informal networks. Many of them migrated to work in factories, mostly within the growing garment industry. Some migrated to work in entertainment venues, such as beer bars, karaoke bars and discos, and many of these may have engaged in transactional sex or sex work. Other women have migrated into domestic work - although no specific studies appear to have focused on them as a group. The reviewed research pointed to birth position in the family as significantly affecting a females decision to migrate, or a family encouraging a daughter to leave home. First-born daughters were disproportionally represented when compared with first-born sons among migrants. Last-born daughters are least likely to migrate. The underlying dynamic may be the practice in which the last-born daughter inherits the natal house and most of the land in return for taking care of the elderly parents,40 resulting in first born daughters taking on the role of supporting their parents and younger siblings. Women of ethnic origin in northern Lao PDR appear to be increasingly taking the migrant path - first due to resettlement from highland areas to lowland
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areas but, more recently, to avail themselves of opportunities to improve their financial and social standing, primarily through work in beer bars and other entertainment venues.41 Many have reportedly ended up selling sex. According to a 2009 ADB report, Once they reach the drink shop, young women are sometimes forced into commercial sex, but more often they are subtly pressured through the disparity in income between selling sex and washing dishes, or just serving beer. One way or another, most women in these venues end up selling sex regardless of original intentions. A substantial number, according to the report, were younger than 18 years.42 2.5 Migrant women occupations This section describes the main occupations that internal migrant women tend to engage in, which has been largely factory work and service work. (Service woman is the commonly used term for sex worker in Lao PDR, although in the context of this review, the more widely used term sex worker is used). It also highlights some of the reported concerns and vulnerabilities of women in those jobs, relative to their sexual and reproductive health. Irrespective of occupation or reason for migrating, the majority of female migrants, as reported in the reviewed literature, were unmarried. Some were encouraged to leave home to support the family, while others left voluntarily to seek new experiences, almost as a rite of passage. Factory workers One of the main employment options for women migrants is factory work, mostly within the garment industry, but also in the wood processing, rubber and weaving industries. Rural-to-urban migration to work in factories is a relatively recent phenomenon in Lao PDR and has increasingly gained acceptance within rural communities as a household economic strategy. The largest numbers of production workers cited in a 2010 report were in the textile and garment industries, of which 85 per cent were female; an estimated 80 per cent of the garment factory workers were internal migrants. Factories recruit predominantly young, unskilled females, based on the stereotypical assumption that they will work effectively at monotonous tasks and will be easy to control.43 None of the reviewed literature mentioned whether ethnic groups were particularly represented as factory workers. Anecdotal information suggested that some ethnic groups may have been more highly represented in factory work, such as Thai Deng and Khmu women.
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Garment factory workers are transient workers and, generally speaking, do not engage in factory work for long periods of time. It is fairly common that these women leave their employment due to the very difficult working conditions, such as long working hours and limited free time, especially when compared to the perceived advantages of service work. Phouxay and Tollefsen (2010) suggested that when women receive information from friends or relatives about other jobs with better conditions, they move on. In different ways, workers adapt to the temporary nature of each situation by being patient, working hard and seeking a future change of some form.44 The qualitative studies on women engaged in sex work by Tan (2006), Sene-Asa (2007) and the Burnet Institute (2008) documented how women moved from factory work to employment in beer bars or an entertainment complex. Although some women left factory work to pursue sex work, others remained, but sold sex as side-line work. This represents a very vulnerable group, considering that the majority of labour migrants have been young women. Tans research on sex work in Vientiane, 2005-2006, revealed that more than half of the women surveyed used to work in agriculture (28.5
14
per cent) or in a factory (27.2 per cent), while 16.7 per cent of them were students. 45 Factory management commonly tries to control its employees, who are provided accommodation in dormitories on the premises, with strict rules on freedom of movement. However, Phouxay and Tollefsen (2010) noted that despite the control measures, some workers escape and work outside at night with part-time jobs in, for instance, restaurants, hotels, garment shops, beer shops or karaoke entertainments. These jobs pay better than factory work, and some women would eventually leave the factory, while others had to return to the factory. These back-and-forth movements caused concern among women who were worried about friends who changed their behaviour and broke rules to work outside the factory at night.46 This study indicates a cultural shift, in which women have more recently pursued employment opportunities likely to result in sex work, while also acknowledging the cultural barriers against it. Some garment factory women became involved in sex work because their income was insufficient to support themselves and their families. Research findings in 2007 from the NGO Acting for Women in Distressing Situations (ASEFIP) offered some reasons as to why migrant women moved from the garment factories to sex work: the need for additional funds to support families in the home village, including the education of siblings; boredom in their garment factory jobs, along with low levels of education - meaning they did not qualify for higher-paying jobs; health problems resulting from the factory work; and conflict and disputes in the factory workplace.47 Another reason why women shifted to sex work might have been to support a boyfriend, or because they were encouraged by their boyfriends to move into that line of work. Decision-making related to the transition seemed to be tied up in a social relationship with someone they knew, such as brokers, friends, relatives or people from the same village.48 Contrastingly, Phouxay and Tollefsen (2010) found that many women do not engage in sex work and worry about the image portrayed. The (factory) workers struggled against negative images of female migrant workers being associated with sex work and/or bad behaviour.49 The 2008 Burnet Institute research suggested that garment factory workers had less awareness about protective measures related to STIs and HIV infection than sex workers. Condom use with regular partners also seemed
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to be low, placing garment factory workers at considerable risk. Additionally, there were lower levels of knowledge about reproductive health, and lower levels of condom use among female factory workers than among sex workers.50 Factory workers thus appeared less able than sex workers to negotiate safe sex, or even whether they had sex at all, due to their young age and relative inexperience. It is not only a lack of information that may result in sexual or reproductive health problems, but also the lack of skills to negotiate relationships and to understand and analyse the intentions of potential partners. The particular working conditions of garment factory workers form a barrier in access to reproductive health information and services. As Kemp found, garment workers commonly live in small overcrowded and uncomfortable rooms in a dormitory without any privacy. Long working hours prevent visiting health care facilities. Some factories have a room for medical care, but the facilities vary in quality.51 Service women and sex workers A CARE baseline study report cited an estimated 4,000 service women associated with sex work, not all whom self-identify as sex workers. These women can be loosely divided into two categories: those working in beer bars and those working in entertainment establishments. Entertainment establishments are large complexes, usually located outside a city and in an economic zone, with a range of employment opportunities including in restaurants, karaoke bars and discos. The number of women that work in these sites varies as they frequently move from place to place, supported by formal and informal networks. An emerging group is that of freelance sex workers, who mostly operate through mobile phone contact. These women differ not only in the approach used for contacting clients, but also in their networks and protection systems, which could also have an impact on their risk behaviour, and on their health seeking behaviour.52 Lao PDR sex workers have a different profile compared with those in some other countries. For instance, sex workers who operate in beer bars or other venues associated with the entertainment sector are frequently paid to be drinking companions and to provide company to clients. Sometimes this relationship leads to sex for money. The reviewed studies described the
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interaction as one of courtship and flirtation between the client and sex worker, even though the women are paid to be there. They generally stay in the business for an average of one to two years and generally have fewer sexual partners when compared with sex workers in some other countries. Not all beer promoters appeared to face the same risks. Webber and Spitzers 2009 qualitative study, focusing on sexual and reproductive health issues facing beer promoters in Cambodia, Lao PDR, Thailand and Viet Nam, reported that Lao participants, who all worked for one national beer company, had benefited from the introduction of specific measures designed to protect them from potential harassment from clients. These beer promoters generally spoke with pride about their company as they felt the company had taken the initiative to develop policies that would protect their safety. For example, staff were not allowed to sit, eat or drink with clients, so as to minimise unwelcome attention from them, and transport was also made available by the company for staff to travel to and from work.53 Tans 2005-2006 research on women sex workers in Vientiane, found that two-thirds of the 312 respondents worked for less than one year, averaging 3.4 months.54 Many sex workers said they intended to stay in the business only long enough to make sufficient money to ensure financial stability for themselves and their families. Research supported by CARE in 2009 found that many such women would have liked to have had one man who will provide for the sex worker financially so that she can set out on her own, even though she may not stay with him long term. Little or no emotional attachment seemed to be associated with the man, although he was expected to set the sex worker up for long-term stability.55 The Tan research also found that two-thirds of the respondents were internal migrants, mainly from the central and northern provinces, with very few of them from the southern provinces. Economic motivation was the main reason they cited for becoming a sex worker (80 per cent). The women reported coming from impoverished situations, living either in the countryside, where it was increasingly difficult to earn money from agriculture, or working in factories, where the wages were not sufficient to send money to their families, and the working conditions were hard.56 The frequency of reported transactional sex demonstrated the important influence of financial concerns on sexual behaviour. In a country such as Lao PDR, where many women often do not self-identify as sex workers, and may have transactional sex as rarely
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as once a week or once a month, their decisions about when to engage in sex for money appeared, to some extent, to be dependent on how much money they needed at a certain time. Another reason given for commencing sex work, particularly with the relatively high financial value placed upon virginity, was the financial need of young womens families, thus illustrating the particular vulnerability of coming from poorer backgrounds.57 Despite the financial utility of transactional sex, exploitation was commonly described in association with the practice, particularly among women working in the service industry, including from their commercial clients. Domestic workers Discussions with researchers and development practitioners58 suggest that it has been less common for Lao women to migrate internally for the purpose of engaging in domestic work, with families in urban areas preferring to source domestic workers who are relatives, or from the same ethnic group. With an emerging middle class, this group is expected to grow. However, with no legal contracts or other protective social mechanisms, this group will also be vulnerable to exploitation and abuse. 2.6 Programmes targeting internal migrants Currently, it appears there are no programmes that specifically address the sexual and reproductive health of women migrants in their role as migrants. Although the national reproductive health programme targets the whole population, including those in ethnic areas, and there are some specific interventions targeting at risk groups, such as factory workers or sex workers, no specific initiatives were identified that focus on the particular vulnerabilities of migrating women. However, when major road or dam constructions are initiated, HIV-prevention components are increasingly being included to protect populations from the spread of STIs and HIV. Because many women migrate to the construction sites, such initiatives provide a valuable service. It is possible also that women migrants may have benefitted from various existing initiatives at different stages of their migration journey. For instance, Population Services International (PSI) - a non-profit organization that offers targeted behaviour change interventions, social marketing products and services for preventing STIs and HIV - operates condom social marketing
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and HIV awareness campaigns that target beer bars and other known places with sex workers across the country. It is possible that if a migrant woman has at some time worked in a beer bar, she will have received the HIV-prevention materials distributed there. The same woman might also, possibly, have been to a school that taught the life skills curriculum. Although no examples were identified of interventions that directly targeted internal migrants, there were some programmes that targeted urban populations which might have included internal migrants; there were also programmes that targeted factory workers and sex workers - groups believed to include large numbers of migrant women. The section below thus describes examples of programmes that have targeted groups known to include internal migrants - with the additional caveat that none of the programmes have been evaluated, thus the outcomes are unknown. Some of the service providers targeting vulnerable population groups are NGOs, supported by external funds, usually implementing activities in collaboration with government partners:
PSI supports drop-in centres where sex workers can access HIVprevention materials and referrals for STI treatment and HIV counselling and testing. This STI and HIV prevention programme targets female sex workers, with the aim of promoting correct and consistent condom use with all sex partners, including regular, casual and commercial partners. Outreach services have been provided to more than 3,000 female sex workers in 11 provinces. PSI also conducts edutainment activities to reach potential male clients of sex workers, with information on health risks and the need to respect women.59
Family Health International (FHI) - a global health and development

organization - relies on paid outreach workers to conduct HIV awareness and prevention interventions among sex workers in venues in Vientiane where people seek commercial sex, such as drink shops, night clubs and karaoke bars. Drop-in centres in targeted districts provide services including diagnosis and treatment of STIs, and condom distribution, and also provide a base for the outreach workers.
Vientiane Youth Centre for Health and Development, managed by the

Lao Womens Union, has an on-site clinic that provides reproductive health services for young people, and also receives referrals from partner
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institutions targeting sex workers. Centre staff also conduct outreach activities targeting garment workers. The Vientiane Youth Centre Clinic does not specifically target migrants, but does provide services for unmarried young people. The Youth Centre clinic also refers clients to other youth-friendly service providers that constitute the partners in a Referral and Counselling Network (RCN), an initiative focused on providing client-oriented quality information and services to young people, linking five member hospitals, the Vientiane Health Departments in nine district hospitals, rehabilitation centres and counselling centres.60 A general assessment described services offered through the network as basic sexual and reproductive health services, namely VCT and STI testing and treatment, condom use for both protection and contraception, with three hospitals providing treatment and support for people living with HIV.61 Despite being the only such initiative in the country, concerns were expressed in the assessment about clients having difficulty accessing facilities due to distances from their locations; inconvenient opening hours; and, in some facilities, no room for clients to wait for counselling, testing or clinic services. The report also noted that not all the staff in the network providing services to young people had undergone training on adolescent reproductive health.62
CARE International - an NGO working to end poverty through

community-based efforts targeting women - supports a programme focused on strengthening protective mechanisms for sex workers. CARE has set up peer protection groups for sex workers, and initiated activities to sensitize police and law officials on human rights. Between 2002 and 2004, CARE also funded a pilot project targeting garment workers in ten factories in Vientiane. The initiative focused on providing reproductive health information, using a peer-education approach, and services, to female factory workers.
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CHAPTER THREE
Review Findings
The following section describes the documented sociocultural influences that have likely impacted on female migrants sexual behaviour and, where such information was available, related access to information and reproductive health services. This has been done by triangulating information from literature sources that do not directly address internal migrants or their reproductive health needs, but which describe the situation of groups known to migrate. 3.1 Education and social change Although migrating women do not all share the same profile, analysis of the reviewed research suggests that most young women who choose to migrate are to some extent educated and do not represent the poorest people in a community. As Rigg noted in 2007, poorest villages in Laos do not have the
Prince Roy / flickr
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highest levels of mobility and the poorest households are not more likely to engage in migration than the less poor.63 In general, there has been a higher propensity to move among women aged 15-29 years who are literate and have an upper secondary school education. Phouxay et al. (2010) wrote that migrants on average have higher education levels compared to those who stay.64 Chamberlain also noted, in 2000, that service women in the north were from a number of different ethnic groups and were clearly distinguished by their much higher-than-average education.65 Poverty-related factors appear to have influenced the decisions of many young women to migrate. Sometimes this has resulted in them engaging in what would previously have been unacceptable types of work. However, families who become accustomed to regular remittances may not question their source, or the possible occupation of the migrant daughter. Rigg described a daughters decision to migrate as an evolving process of empowerment while also economically serving her family: What began as an opportunistic, possibly even off-the-cuff decision, became over time entrenched. Gilis reluctant parents became willing supporters.66 The reviewed literature conveyed that increasing numbers of females from ethnic groups have migrated to urban centres as a consequence of social change in their communities of origin. Reports reviewed indicated that some ethnic groups have been more predominant among the surveyed migrants, such as the Thai Deng, a lowland people who have a large existing network that facilitates movement. The Khmu are a highland people who also have migrated widely across the country. 3.2 Migrant networks Migration is facilitated by various forms of networks, including word-ofmouth recommendations from women returning to their villages with new perspectives, new clothes and possessions. Often, explained Rigg in 2007, these discrete networks of social relations and contacts link the source communities with particular places and job opportunities, and these are more important than distance in determining levels of outmigration.67 Migration can be mediated by contacts and through interactions with relatives and friends who have previously migrated and are visiting the home village. In these instances, kinship clearly plays a hand in the migration process. These networks often assist with employment contacts and places
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CHAPTER THREE: REVIEW FINDINGS
to stay in the destination areas. Such networks provide some security for young women who migrate and for the families that they leave behind. Most examples related to this type of arranged migration were cited in the literature on migrant women engaged in factory work. In some cases where the family and community has facilitated the migration, some degree of control has often been maintained over the migrant, at the same time providing protective security. Phouxay and Tollefsen noted in 2010 that there are informal migrant networks in which families extend their control over young women and their income, thus reinforcing links with their families and communities of origin.68 Other women choose to leave home to escape family and household duties. Phouxay and Tollefsen note that, Some young women migrated against the will of their families, relying wholly on networks of friends rather than kinship networks. There were young women who longed for a life without farm work and wanted to be with their friends in Vientiane capital.69 These women are particularly vulnerable without the protection that a connection to the family and home community entails. It can be surmised that, in terms of reproductive health information and health-seeking behaviour, networks of friends can potentially be sources of information and support, including for seeking services. Doussantousse et al.70, as well as Lyttleton and Vorabouth71, described the role that social networks played in facilitating the migration process with reference to the large number of Khmu women who have left their villages to work in bars, eventually becoming engaged in sex work. Bar owners, they pointed out, frequently ask young women working for them to recruit other young women from their villages so as to maintain a flow of new staff. Sometimes they even provide an all-expenses paid trip home to the staff to encourage this recruitment, or pay them a brokers fee. Bar owners also make direct contact with villagers, usually through connections with existing staff, or by circulating their mobile phone numbers. Additionally, as the apparent wealth of young women who have left home to work in the service industry becomes more visible in villages (through the construction of new houses and the opening of shops, for example) other young women are attracted to the same path. Network-supported migrants have important help in their place of destination, not least in terms of personal and emotional adjustment to an often difficult
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situation, wrote Phouxay and Tollefsen.72 Information on reproductive health services (such as how to obtain an abortion) is usually provided through the network of friends or, in the case of sex workers, the mamasangs, who typically run the beer shops and manage the women who work there. In the case of sex workers, according to a 2009 CARE report, key relationships revolve around the sex worker community. Relationship dynamics with those outside the community are often defined by their form of employment.73 This situation has been similar for garment factory workers and other groups, and suggests a potential entry point for reproductive health information. It can be presumed that because networks play an important role in the recruitment and support of migrant workers, that they would also play a part in supporting women with respect to their health, and when they experience violence. The literature reviewed provided very little information on this. In terms of gender-based violence, there were references to a variety of actions that sex workers had taken after experiencing exploitation or abuse and for which internal networks were assumed to have an important role. The most common cited source of support in the event of exploitation or abuse, whether physical, emotional or sexual, has been from fellow sex workers and friends. Peers may also give practical support in response to an abusive act.74 These findings demonstrate how such groups have remained selfcontained, relying on their own networks and support systems. None of the reviewed literature described action taken by factory workers in the event of violence and abuse. However, given that many factory workers travel and work together and, when in factories, live together, it could be assumed that support will primarily be sought from workmates. With respect to Khmu women working in bars in rural areas, Lyttleton and Vorabouth75 also explained that some bar owners have assumed an extended family ethos, taking on a role similar to that of a surrogate parent, which included taking care of the health of women working for them. Given the nature of the employment, it is likely that this would include visits to hospital for matters relating to sexual and reproductive health, though this was not specifically mentioned. 3.3 Ethnicity Reviewed literature suggests that there is a link between ethnicity and some forms of migration. Most of the qualitative studies reviewed that focused on
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factory workers and sex workers in urban areas did not however disaggregate respondents by ethnicity, so it is difficult to assess to what extent ethnic groups are represented, overall, within the migrant population. Several studies were identified that focused on changes affecting selected ethnic communities in northern Lao PDR, particularly in Luang Namtha province. These provide rich information on how migration associated with relocation has resulted in ethnic women becoming involved in the sex industry. Although a valuable source of detailed information, these studies cannot however be seen as representative of all ethnic people in the Lao PDR, as they focus on only a few groups in the north of the country, which have distinct cultural beliefs and practices. Literature describing involvement in migration among ethnic groups in other parts of the country, particularly the south, was not identified. Chamberlain argued that among certain ethnic groups, the education system had provided access to literacy, and that learning the Lao language had allowed movement into areas of economic endeavour previously inaccessible by social and cultural barriers.76 Furthermore, the high degree of correspondence between minority womens education and the sex worker occupation cannot be coincidental. Minority women have the least amount of education and educational opportunities and yet the service women working in the establishments surveyed have the opposite profile.77 One recent trend that is a direct consequence of the bars and economic transitions facilitated by the presence of the road is the increasing commodification of sexuality amongst ethnic groups, Lyttleton recently concluded.78 Some of the reviewed literature argued that traditional sexual practices of certain ethnic groups might influence or facilitate decisions to migrate, as well as choices to engage in sex work. It has been argued that the flirting behaviour between sex workers and their clients has similarities with traditional courtship behaviour within specific ethnic groups. For instance, within the Khmu and Akha ethnic groups, premarital sexual experimentation is accepted.79 Khmu, Thai Deng and Akha are ethnic groups whose traditions related to sexuality could possibly place women in vulnerable positions because premarital sex is permitted in certain circumstances. It was not rare to find in the reviewed literature that sex workers in the northern provinces often came from the Khmu and Thai Deng ethnic groups.
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Lyttleton and Vorabouth, in a 2011 study, described the rapidly evolving situation in northern Lao PDR, in which ethnic women were increasingly engaging in sex work as a way to support their families, and also to improve their own economic and social standing. Bar owners, they noted, use the ethnic women they employ to recruit other young women from the same villages. Poor families, with daughters who left school before completing primary education, are often targeted. This finding is different to that from earlier studies cited, which suggested that migrant women - including ethnic women - have usually had some education, and might be indicative of more recent local migration in the northern region. Among the Khmu who are well represented in the service industry in northern Lao PDR, premarital sex is not taboo, although there are clearly prescribed traditions surrounding when and where such activity may take
26
Zalzadore / flickr
place. Within the village, each house is protected by customary spirits, and it is understood that no sexual impropriety should take place within the home for fear of offending these spirits. Young people thus engage in premarital sex outside of the home. Lyttleton and Vorabouth described how these traditional beliefs might be interpreted to support the increased involvement in the service industry: In conjunction with the appeal of outmigration, there are mechanisms in local Khmu belief systems that to some extent privilege sexual interaction away from the home.80 The authors argued that the Khmu have shown a cultural willingness to inhabit a low social and economic niche in the service industry (as sex workers), in keeping with the inferior status they have long suffered in relation to the majority Lao Loum population.81 And yet they are reportedly resourceful at what they do: in Lao PDR there is a widespread assumption that females who are new to sex work have more clients than others. Responding to this perception, and using their networks and social contacts, Khmu women engaged in sex work reportedly move from location to location to appear as new and thus best maximize their income, typically moving on every two or three months. Lyttleton and Sayanouso, in another 2011 study, described how relocation from highland to lowland areas - equated with migration because of the enormous social changes entailed - now exposes Akha women in Luang Namtha province to risks associated with engaging in commercial sex with men from outside their communities. Chinese migrant labourers and Lao men from nearby towns visit the villages to negotiate sex with Akha women. Traditional practice allowed for women, on occasion, to sleep with visitors to the village, but evidence shows that they are now beginning to exchange sex for money.82 There is also increasing evidence of sexual partnership and even marriage between Lao Akha women and Chinese Akha men. The former are seeking to advance their social positions, while the Chinese Akha men are seeking to advance their economic opportunities across the border inside Lao PDR. The authors noted that while advantage is being taken of newly formed networks through a common ethnicity, the Lao Akha are not yet migrating to Lao cities as language and lack of family networks and/or agents promoting its appeal so far preclude this.83 Referring to the potential for HIV transmission, Chamberlain observed in 2000 that multi-partner sexuality is typically associated with the ethnic people living in the northern provinces, when sexual interactions create
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networks that extend beyond cultural groupings, the potential for infection is increased dramatically.84 This would also encompass risk of infection from other STIs. After reviewing studies and data from between the late 1990s and 2004, Lyttleton noted that at the time of writing (2005), although no HIV testing had been done among the Akha in Muang Sing and Muang Long districts, gonorrhoea was already endemic in some villages. In 2008, a decrease in STI prevalence was noted at the national level, although in Luang Namtha province, where Muang Sing and Muang Long are located, there was a minimal decrease.85 This finding might be associated with the high level of infertility experienced by the Akha.86 Language Among the ethnic population in general, language and cultural barriers have been found to be primary factors affecting their access to reproductive health information and services. A 2005 study on reproductive health services in ethnic villages, for example, mentioned that male and female community members in all target villages had minimal or no oral Lao language skills.87 However, given that most ethnic women who have migrated appeared to have had some education (which is in the Lao language), it seems unlikely that language would be a significant barrier to them accessing health services. 3.4 Gender Evolving roles as independent women In Lao PDR, the gender gap is still pronounced, especially among rural households, poor households and ethnic groups. However, migration has helped change perceptions of gender roles and gender relations. Female migration represents a shift in womens roles, both in terms of how women are perceived, as well as how they perceive themselves. Rigg found that at the village level, cultural norms that once limited the mobility of young women quickly fray and migrant daughters become an accepted part of normal living.88 Women, including some ethnic women, are now empowered to move away from traditional roles and experience independence and the ability to financially care for the family. Migration to urban-based factories has modified gender roles and womens status, both inside and outside the factory. Within Lao society, there has never been a very strong notion of the man as the breadwinner - women
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are seen to be just as important in this role. If parents could not support the family or the childrens education, the oldest daughter felt compelled to drop out of school and move to work in the city in order to help them, explained Phouxay and Tollefsen.89 In their separate reports on similar topics, Rigg in 2007, and Phouxay and Tollefsen in 2010, discussed the concept of the dutiful daughter, referring to the socially constructed expectation placed on daughters to migrate and earn money for the sake of the family. Daughters send remittances home for the benefit of, for instance, a brothers education, or for the household economy. This can lead to negotiation of a new social position by the daughter, which might be a source of empowerment. However, the researchers argued that although migrant work may be empowering in the short term for young single women workers from rural areas, in the long run they are still expected to return to the village to marry and uphold household and village responsibilities.90 Migration is also a form of self-empowerment. Women who have left their communities in pursuit of work have done so with the expectation of improving their own and their families lives. Phouxay and Tollefsens 2010 study on female industrial workers revealed that the need to leave was not only for income, employment and remittance purposes but also a part of growing up and assuming the task of providing for others. For many women, the significance of their rural-to-urban migration related to identity, status and desire for a modern urban lifestyle. Factory work was seen as an income opportunity not only for the family but also for themselves as individuals.91 Women who left home to work away may have sent remittances back to the family and community, but at the same time they also enjoyed the relatively independent lifestyle and the sense of being a modern woman. Still, although migration has been an economic survival strategy for many women, they also had to reconcile their economic and consumption aspirations with commitments to rural kin and communities.92 The study highlighted a number of positive impacts. In particular, migration led to new skills, increased opportunities, and later impacts on smaller family size and increased investments in childrens education. According to Phouxay and Tollefsen, although factory work was seen as temporary, work in the city was mostly perceived as a permanent strategy; the stay in the city could be prolonged because it was not predetermined that women should return to their rural community. Although commitment
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and ties to rural families remain strong, another strategy has been to bring the family to the city. The researchers also found that families in places of origin did not have total control over the daughters earnings; daughters sent remittances but also saved some for themselves.93 Regarding ethnic women engaging in sex work, Lyttleton and Sayanouso suggested that both Akha94 and Khmu95 women were using their own agency to move beyond traditional roles held by women in their original highland communities by engaging in sex work, which enabled them to improve their status (at least for the Akha) and economic standing, while at the same time supporting their families in the village. In the case of the Khmu, the authors also suggested that family compliance and acceptance might have been obtained because of the perceived similarities between serving clients in bars and restaurants, and the traditional role of women serving drinks in Khmu social gatherings. According to custom, male peers from an Akha village would traditionally serve as interlocutors between young women and Akha male visitors from outside villages, negotiating a sexual liaison. They would receive alcohol and cigarettes in exchange for this service. Following migration to the lowlands, however, young Akha women have been using their own agency to conduct such negotiations and have used sexuality as the formative stepping stone to other forms of social and economic advancement.96 Young Khmu women are now considered as a more reliable source of income for the family than in the past. Due to an increasing reluctance to marry early (sometimes as young as 14) and to engage in hard labour in the fields, they reportedly prefer to play around first and to earn income that they can invest in small local businesses, such as a shop. Thus the gender roles of some Khmu women have been gradually changing. Traditionally, male migration was more common among the Khmu, but increasingly young women constitute a greater proportion of migrants. Lyttleton and Vorabouth refer to a quoted Khmu who, referring to traditional culture, said, To have a daughter is to have rice, to have a son is to have money.97 This indicates the changing roles of women associated with the move from subsistence farming, now that land and forest access is restricted, to that of a woman who is earning income.
Narisa Spaulding
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Gender-based violence Women who migrate internally, for whatever purpose, are vulnerable to gender-based violence. Most of them likely lack negotiating skills and have limited options to assert themselves. They often end up dependent on boyfriends, and thus vulnerable to being exploited or abused. Although gender-based violence can be found in many communities and within ethnic groups in Lao PDR, female migrants are particularly vulnerable because they may have no alternative or independent support mechanism outside of that which is provided by the very people who subject them to abuse. According to the reviewed literature, there is also a lack of awareness of their legal rights and lack of access to legal services. This situation is exacerbated by unsupportive law enforcement officers and a weak legal framework. In general, there is a lack of protection mechanisms in place. A 2008 PSI study reported that 22 per cent of the respondents had been forced into sex during the year prior to the survey, 5 per cent had been punched or hit by a client in the previous three months and 51 per cent had been forced by a client to not use a condom in the previous three months.98 Some sex workers described increasing difficulty in addressing aggressive sexual practices. The Burnet Institute reported in 2008, Service women said that some clients gave them drugs because they wanted the service women to have harsh and sadistic sex.99 Women working in the sex industry have been reluctant to approach the authorities when they have been abused because they were typically treated as sex workers without rights, and not as women with rights; they had a poor self-image and did not have confidence in the legal system.100 With sex work regarded first and foremost as illegal, and associated with social stigma, violence against sex workers has been considered as deserving of less attention than violence against women among the general population. If sex workers approach authorities for help as victims of abuse, they will not be afforded the same rights, noted Garraghan, suggesting that the illegal status of sex workers would affect their access to legal services and they really would only be granted access if they showed willingness to change jobs.101 Re-education and encouraging a sex worker to change occupation seems to be a priority, rather than the provision of legal services in accordance with her rights. An example of how sex workers rights as women are over-ridden by their status, is the contention that rape is not applicable in the case of a sex worker
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due to the nature of the job.102 This illustrates the vulnerable situation in which sex workers operate. They thus must rely on their own networks, seeking services and information through alternative channels. Reviewed literature suggests that sex workers perceive health service providers in government facilities as unhelpful and as discriminating as the legal authorities, thus further inhibiting them from seeking such services. 3.5 Health-seeking behaviour According to the literature reviewed, the main reproductive health needs of internal migrants were contraception, abortion, post-abortion care (to address complications following the use of pills bought over the counter) and access to STI testing and treatment. As described, no documents or references related to maternal health needs of internal migrants were identified through the review. Additionally, no information was found on whether health-seeking behaviour patterns changed for women who returned to their home villages. However, it might be the case that internal migrants who returned to their community of origin to settle down and start a family might be more inclined to seek maternal health services than those who never left that community. Returning migrants may have had greater exposure to the health system, even if they had not used it. Despite facing particular vulnerabilities and stigma, returning migrants may also return with a greater sense of empowerment due to their financial independence, and thus more confidence to access health services. References to facilities where migrant women sought essential reproductive health care, cited preference for over the counter medicines bought in pharmacies, and for drop-in centres and private clinics. Women have chosen to go to pharmacies or private clinics to obtain contraception rather than go to a doctor in a hospital. It was easy and cheap to go to a pharmacy or private clinic. Women mentioned that they prefer not to obtain information about contraception from hospitals. This is due to the lack of privacy, the crowding and long waits involved in visiting hospitals.103 Other barriers that prevented migrant women from seeking public health services were also cited in the reviewed literature. Because of their illegal status and the stigma associated with their work, sex workers expressed reluctance to seek health care in government facilities. Fear of authorities, negative service provider attitudes, and inconvenient opening hours and availability of services were also described; these were also barriers
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preventing factory workers from using public health services. The status of being an unmarried woman has been another prominent barrier, especially in terms of accessing contraception. Abortion is illegal under most circumstances in Lao PDR, but several sources mentioned the high level of women who have had an abortion. The PSI survey conducted in four provinces in 2008 revealed that unprotected sex was common and was resulting in unwanted pregnancies and abortions. Both traditional methods and modern pharmaceuticals are used for inducing abortion. The reported evidence of women treated for complications from abortion points to high rates of unsafe abortion among different age groups. Owing to socio-cultural influences as well as financial constraints, abortion is more likely to be performed under clandestine and unsafe conditions by untrained practitioners.104 In the sexual behaviour survey conducted in 2008 by the Burnet Institute in Vientiane, 23 per cent of the respondents reported having had an abortion.105 The majority (69 per cent) reported making the decision on their own, almost half of whom secured the abortion at a private clinic. The majority of the women took pills, identified as Chinese medicine, to induce the abortion. The reviewed literature indicates a clear preference for visiting a pharmacy or private clinic, rather than a hospital, when it comes to needing advice or assistance for unwanted pregnancies. In terms of vulnerability to STIs, rates of condom use among sex workers have increased over time. However, an ADB study found in 2009 that although knowledge of HIV prevention and condom use was widespread in villages around the recently conducted Route 3 where awareness-raising campaigns on HIV prevention had been conducted, condoms were still not used consistently. Additionally, women working in bars have reported not using condoms with regular partners or men they regard as boyfriends.106 This was similar to findings of the PSI study, which reported sex worker use of condoms with commercial partners had increased from 82 per cent in 2005, to 89 per cent in 2008. However, only 45 per cent of respondents reported consistently using condoms with regular partners (boyfriends).107 Doussantousse et al. mentioned that most sex workers in bars accept that they have to pay for their own medical costs, although one mamasang said she keeps medicines on hand and dispenses them free to her workers, and another said she calls in a nurse and pays for the treatment if it is under 50,000 kip (US$6).108 The report did not state the nature of the medical complaints experienced by the bar workers. Doussantousse et al. also referred
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to a Luang Namtha pharmacist who reported selling condoms regularly to bar owners and another saying that she sold over the counter treatment for gonorrhoea to sex workers. 3.6 Health service provider attitudes There was no specific reference found in the review on health care providers attitudes towards internal migrants, although there were sources that described how women perceived provider attitudes and the provision of care in general. As already noted, it is possible that internal migrants, especially those working in factories and the service industry prefer not to approach government health facilities for a variety of reasons, including long waiting time, inconvenient opening hours, a fear of authorities and insensitive attitudes that service providers project. Based on its sexual behaviour study in Vientiane, the Burnet Institute reported that service women said that they did not access the general health care services due to discrimination and social stigma.109 There has been a general perception that health care providers adopt judgemental attitudes towards some females, especially those who are unmarried or from ethnic minority groups. The reviewed literature on the health-seeking behaviour of young people can possibly also shed some light on the health-seeking behaviour of young migrant women. The 2008 UNFPA assessment on youth-friendly service provision, for instance, found that most young people are unwilling and unable to use health services for several reasons, such as lack of awareness of existing services, confidentiality concerns and lack of privacy in health facilities, embarrassment, and the perception that health providers are judgemental and unwelcoming to young clients.110 3.7 Return and reintegration According to interviews with development practitioners,111 reintegration into source communities seems fairly easy and women commonly return to marry and start a family. Rigg observed in 2007: The large majority of migrants do return home. Migrants acquire, at best, only low-level skills and the moral imperative to return home remains strong.112 Other sources, though, suggested that these women do not expect to marry or go home. It may be likely that very few want to return to agricultural work, but may be interested in moving to their home village to pursue other economic opportunities. According to Tan, 29 per cent of the service women respondents in the
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2005-2006 Vientiane study expected, or had an ambition to work in other service activities, such as hairdressing or tailoring; and approximately 28 per cent expected to save enough money to run their own small business.113 Lyttleton and Vorabouth described the apparently easy transition in which many Khmu women had returned home with their newly acquired wealth, set up businesses and even married. Women who return from work in drink shops are sometimes subject to subtle gossip, but in the villages we visited there is no persistent stigma and many subsequently take husbands in their home or neighbouring villages.114 However, other reports suggested that returned migrants in rural areas have not always reintegrated with ease into the social and economic situation. There were often presumptions made about how they had earned their income. Discrimination and suspicion towards returning migrants seems to be gendered, with villagers and government authorities possibly suspecting that the female migrant may have been engaged in sex work or other lessthan-reputable work, noted Doussantousse in 2006.115 If a woman has engaged in sex work, it is unlikely that this information is disclosed to the family and community. Also, even if a woman had worked in a factory, Phouxay and Tollefsen found examples of certain stigma attached to that work, Workers had to struggle against negative images of female migrant workers being associated with sex work and/or bad behaviour.116 Migrants have also had to grapple with the space between traditional village life and the migrant lifestyle, not fitting completely satisfactorily into either place. Riggs study on the status of female industrial workers presented the dilemma many migrating women have experienced between their different localities: Women who have migrated and returned to their community perceived that local people disliked and looked down on them and thought they acted against Lao women culture. Similarly, migrants felt that people in destination areas also disrespected them. It was striking how women struggled with negative pressures from home and destination communities, but were also determined to care for themselves. Women had to negotiate their status and identities, both in their villages of origin and in the city. Being female factory workers had largely negative connotations, which women felt were unfair and ungrounded.117
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CHAPTER FOUR
Strengths and Gaps

4.1 Research The main research gap identified through this study is the absence of comprehensive reviews that specifically examined the situation of internal migrants in relation to their sexual and reproductive health. There is also a general lack of information on the profiles of migrants: who they are, where they come from, why they migrate, and the main transition paths. In the absence of such literature, or evidence of related programmes, and given the increasing amount of internal migration in Lao PDR, it is likely that there may thus be many unmet needs.
International Rivers
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Despite the absence of literature relevant to the focus of this review, a number of studies have been conducted that tangentially address migrant women and related health needs. Similarly, a few projects have directly or indirectly targeted migrant women, due primarily to a specific occupational or age focus. Importantly, there is very little direct information on the extent to which socio-cultural factors impact on the health and decision-making behaviour of migrant women. Additionally, no information was identified that describes what migrant women do once they have left their occupation or destination locality and returned home. Although the literature suggests that many migrants return to their communities of origin, there is a lack of information on how the overall migration experience has affected their sexual and reproductive health behaviour, or their health-seeking behaviour, and only limited information on whether or how cultural norms may be changing as a consequence of womens increased economic empowerment and independence. 4.2 Programme gaps and possibilities for replication One commonality among internal migrants that appeared in the reviewed literature is that regardless of occupation or community of origin and destination, migrant women do not seek health services consistently. A number of interventions have been initiated to provide targeted groups of women identified as at risk with selected reproductive health services. Although, as noted, these interventions have not been evaluated and may not constitute examples of good practice, they could perhaps be used as models for developing services that specifically target migrant women. Such interventions could be scaled up if evidence shows that they are providing appropriate, client-friendly services that could be modified or replicated to target migrant women and girls. One model for possible replication is the FHI-managed drop-in centres targeting sex workers in four districts of Vientiane (Saysetha, Chanthaboury, Xaithany and Sikhot). The drop-in centres provide sexual and reproductive health information and refer clients to service providers who have received training in responding appropriately to sex workers. The majority of clients have been female entertainment workers, indicating that the drop-in centres are conveniently located in areas with a large number of entertainment venues.118
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CHAPTER FOUR: STRENGTHS AND GAPS
Gz / flickr
PSI, with support from UNFPA, plans to initiate a social marketing scheme for reproductive health services that will include identifying a network of affordable service providers. Migrants are not specifically mentioned as a target group, but the services will be directed to groups that include migrants, such as sex workers and garment industry workers. This initiative has the potential to increase access to health providers that will be rated in terms of quality. The support mechanism introduced by the Beer Lao company to protect beer promoters from potential harassment from male clients is a positive example of an employer taking responsibility for staff health and welfare. The company disallows female beer promoters to sit, drink or eat with clients, and provides transport to and from work.119 Staff appreciated this concern and regarded themselves as being better off than their counterparts working for other beer companies or private bar owners. Initiatives such as this could be replicated.
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CHAPTER FIVE
Conclusions and Recommendations

Using the range of materials available, this review gathered what limited information was available on socio-cultural influences on women migrants sexual and reproductive health. The reviewed literature describes how women migrate for a variety of reasons and that there are only limited options available to them for employment purposes. It describes how the migration experience is likely to be different according to the type of employment a woman engages in, whether or not she comes from a specific ethnic group, and whether she has left home with or without family and community approval. Commonalities include migrant womens vulnerability to exploitation, sometimes resulting in acts of unprotected sex leading to unwanted pregnancies and unsafe abortion. Migrant women are also vulnerable to gender-based violence and abuse. The literature also suggests that although internally migrating women do not usually represent the poorest of the poor, and are not among the least educated, they nevertheless engage in risky behaviour and are, by virtue of their unregistered and often low status, unable to negotiate with men and to ensure protection and care in matters relating to sexual behaviour and reproductive health. The review has thus generated the following main conclusions:
Lao PDR is facing rapid social change due to development

and the opening of road systems, especially in the northern provinces but also emerging in southern provinces. This has particularly affected rural communities, with evidence of increased access to educational opportunities, a larger role in economic development and associated increased levels of mobility. Previously isolated communities are experiencing increased exposure to the outside world
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and, in some cases, traditional practices and beliefs are waning as communities encounter a modernized market economy that they are not always equipped to deal with.
Ethnic groups are particularly affected by these social changes due to

the geographical and cultural isolation of many groups. Some ethnic groups are represented more frequently among internal migrants (such as the Thai Deng, a lowland ethnic group with a large existing network) and the Khmu (a highland population). Some ethnic groups appear to be more predominantly represented in sex work and factory work.
Most young women who migrate are usually educated to some extent.
This appears to be particularly the case for those who enter into sex work rather than the garment industry. These women are their own agency for change. However, despite some education and a desire to improve their lives and those of their families, these women are vulnerable to exploitation and abuse because they still operate within gender-prescribed roles and have little or no negotiating power in relationships. Additionally, access to health services in many cases is limited by what is regarded as culturally acceptable behaviour for young women, such as sexual abstinence before marriage.
Many young women voluntarily leave home as a rite of passage, driven

by economic needs and expectations, or sometimes lured by the apparent economic benefits and lifestyle that friends have attained by migrating. Some return home, set themselves up in business and marry locally, without apparent difficulty.
In the village, womens behaviour is usually dictated by social and

cultural norms. They are not however usually constrained by such factors when they move away from home to seek external employment opportunities. It is not clear whether returned migrant women are change agents for raising awareness among their home communities on public health services and positive health-seeking behaviour, although this is a possibility. Having potentially been exposed to a wider range of influences, including health services, than those who never left the village, returned migrant women might be less suspicious of institutional health service provision than other rural women, particularly those from ethnic communities. This is speculation, however, and would likely depend on a number of other factors, including a womans experience of
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CHAPTER FIVE: CONCLUSIONS AND RECOMMENDATIONS
public services when she was a migrant worker which, in turn, will be affected by the type of work she was engaged in.
A significant influence on health-seeking behaviour is the illegal status

of sex workers, which means they are unlikely to seek governmentprovided reproductive health care. Other barriers for migrant women include fear of authorities, discriminatory attitudes of service providers, and inconvenient opening hours and availability of services, especially for those who have limited free time, such as factory workers. Being unmarried is another constraint in terms of access to services. The limited range and coverage of health and social insurance schemes is another limiting factor. 5.1 Recommendations for research The review highlights the overall lack of data and information in relation to the situation of internal migrants in Lao PDR. The main recommendation is thus that more in-depth research should be carried out, including studying the influence of socio-cultural factors on internal migrants engagement in risk behaviours and practices, and health seeking behaviour. Such information could be used by the Government, service providers and NGO partners to inform the design of culturally sensitive approaches that could contribute directly to addressing the reproductive health needs of migrant women through targeted programming. Such research could focus on the impact of socio-cultural influences on knowledge, attitudes and practices, healthseeking behaviour, service provision, gender relations, family composition and size, education and employment. Findings could also be used to inform related policy. Research should be both quantitative and qualitative to analyse the movement of internal migrants. In particular, there is a need for analysis along the migration path, to explore the situation in places of origin, transit and destination, and to examine related socio-cultural influences. Qualitative research should include field visits to communities of origin to interview women who have migrated and returned to their communities. Research should differentiate between various movements because some migrant women work close to their places of origin, while others congregate in economic corridors or urban areas, resulting in diverging profiles. Different approaches to target their needs would thus be required.
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In-depth research needs to be supplemented by a focus on specific migrant groups, such as:
factory workers, to examine the protective mechanisms for those who domestic workers, an unregulated group that may be growing with an ethnic women, to determine influencing factors, particularly risks and sex workers, to determine protective mechanisms
Other recommendations are clustered around advocacy measures that the Government, UNFPA and other development partners could adopt, and around capacity-building initiatives that could be addressed directly by the Government and/or the private sector. 5.2 Recommendations for advocacy Advocate to government and policy makers to: mitigating factors emerging middle class may be at risk of entering into sex work
develop specific policy or policy reforms in favour of migrants, in terms

of registration in non-resident locations incorporate migrant needs into relevant health sector policies, including the National Reproductive Health Policy implement the National Reproductive Health Policy recommendation to introduce emergency contraception promote health insurance coverage for those in formal employment, such as factory workers, and for those working in less-structured employment, such as entertainment venues consider replicating the Referral and Counselling Network in other provincial towns, particularly those with a large influx of internal migrants.
Advocate to workers associations, factory owners and owners of bars and entertainment venues to:
include sexual and reproductive health information and life skills for
employees, including information on health service availability where appropriate, promote consistent condom use with clients and regular partners
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establish on site clinics offering a full range of reproductive health

services on factory premises; alternatively, establish links with external service providers and enable workers to access these facilities without docking their pay promote peer education approaches for information sharing and awareness raising on reproductive health issues, including distribution of condoms, and other contraceptives including emergency contraception beer companies and bar owners could actively protect beer promoters and staff from sexual harassment and violence, through limiting possibilities for unwelcome contact and by providing transport to and from work. Advocate at the community level to:
establish or maintain existing life skills or community programmes in

locations likely to have high outmigration, through which specific information and skills could be provided to address vulnerabilities experienced by migrant women promote peer education approaches for information sharing and awareness raising on reproductive health issues, and for distribution of condoms and contraceptives, including emergency contraception work with existing social structures, such as village leaders and bar owners, to ensure that condom use is promoted at all times for women working in bars and other entertainment venues. Advocate with development practitioners to:
ensure that provisions are included in large-scale development

programmes, such as dam and road construction, that offer comprehensive reproductive health services for migrants ensure that programmes targeting those affected by infrastructure developments should address not just communities within their immediate radius, but also those within the broader orbit once construction is completed120 extend the duration of awareness-raising programmes beyond the time line of infrastructure development work, because people from a large geographic radius continue to be attracted to opportunities for engaging with the market economy.121
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5.3 Recommendations for strengthening capacity of service delivery Train health care providers to:
provide client-friendly, non-discriminatory
services, especially for unmarried women, sex workers and factory workers (who dominate the migrant population) provide confidential counselling to clients, focusing on unmarried women and those in migrant-related employment address cultural barriers to accessing good health care, especially among ethnic groups in communities of origin and in destination localities promote access to contraception, including emergency contraception, for unmarried women, including migrant women, to address the high prevalence of unsafe abortion train staff in identification of cases of gender-based violence, and establish referral links to counselling and legal services.
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ANNEX ONE
Endnotes
1
UNIFEM was renamed UN Women, or the United Nations Entity for Gender Equality and the Empowerment of Women in July 2010. Phouxay, K; Tollefsen, A. (2010). Rural-Urban Migration, Economic Transition, and Status of Female Industrial Workers in Lao PDR. Population, Space and Place, John Wiley & Sons Ltd. Huijsmans, Roy (2010). Migrating Children, Households and the Post-Socialist State: An Ethnographic Study of Migration and Non-Migration by Children and Youth in an Ethnic Lao Village. Durham University, p. 210. Phetsiriseng, I. (2007). Gender Concerns in Migration in Lao PDR Migration Mapping Study: A Review of Trends, Policy and Programme Initiatives. UNIFEM. ibid., p. 12. Ministry of Planning and Investment (2011). Ongoing study on internal migration supported by UNFPA. The World Bank (n.d.). Ethnic Groups, Gender and Poverty Eradication, p. 27. UN Country Team (2009). Brief for the Committee on the Elimination of All Forms of Discrimination Against Women by the United Nations Country Team in Lao PDR, not for distribution, p. 50. Huijsmans, R. (2010). Migrating Children, Households and the Post-Socialist State: An ethnographic Study of Migration and Non-Migration by Children and Youth in an Ethnic Lao village. Durham University.
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10
Bird, K. (2009). Voluntary Migration in Lao Peoples Democratic Republic. Policy Brief No 3. Prepared for the World Development Report. Lyttleton, C. (2005). Market Bound. Relocation and Disjunction in Northwest Laos in Jatrana, S., Toyota, M. and Yeoh, B. Migration and Health in Asia, p.43. Lyttleton, C. and Vorabouth, S. (2011). Trade Circles: Aspirations and Ethnicity in Commercial Sex in Laos in Culture, Health and Sexuality. Phouxay, K. (2007). Internal Migration and Socio-Economic Change in Lao PDR. The 4th International Conference on Population Geographies. National University of Laos. Huijsmans, R. (2010). Migrating Children, Households and the Post-Socialist State: An Ethnographic Study of Migration and Non-Migration by Children and Youth in an Ethnic Lao Village. Durham University, p. 187. Asian Development Bank (2009). Build It and They Will Come: Lessons from the Northern Economic Corridor for Mitigating HIV and Other Diseases. Asian Development Bank (2009). Migration in the Greater Mekong Subregion, p. 19. Huijsmans, R. (2010). Migrating Children, Households and the Post-Socialist State: An Ethnographic Study of Migration and Non-Migration by Children and Youth in an Ethnic Lao Village. Durham University, p. 107. Garraghan, T.A. (2009). Just Beginning: A Qualitative Baseline Analysis of the Risk of Abuse and Exploitation of Sex Workers in Vientiane Capital and Subsequent Access to Legal Services. CARE, p. 15. Resolution of the Lao PDR Government on National Population and Development Policy. http://www.unescap.org/esid/psis/population/ database/poplaws/law_lao/laopart2.htm#pt1 National Reproductive Health Policy (2005). Ministry of Health, Government of Lao PDR.
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ANNEX ONE: ENDNOTES
21
National Committee for the Control of AIDS (2006). National Strategy and Action Plan on HIV/AIDS/STI 2006-2010. Government of Lao PDR. Manivong, K. (n.d.). Health Financing Reforms in Lao PDR and Key Discussions Towards Social Insurance Universal. Department of Planning and Finances, Ministry of Health. Personal communication with Filip De Loof, former WHO advisor in Lao PDR. Asian Development Bank (2007). Proposed Asian Development Fund Grant Lao Peoples Democratic Republic: Health System Development Project. United Nations Population Fund (2008). Rapid Assessment of the Quality of Implementation of Reproductive health/HIV/AIDS/STI Drugs Education Life Skills Based Education Curriculum. Doussantousse, S. (2010). Life Skills Based Curriculum Project Evaluation. UNICEF, p. 14. ibid., p. 10. Chariyalertsak, S., Shuey, S. and Rattanavong, F. (2001). Primary Health Care Review in Laos. World Health Organization. Asian Development Bank (2007). Proposed Asian Development Fund Grant Lao Peoples Democratic Republic: Health System Development Project. Chariyalertsak, S., Shuey, S. and Rattanavong, F. (2001). Primary Health Care Review in Laos. World Health Organization. World Health Organization, Department of Reproductive Health and Research (2000). A Strategic Assessment of Reproductive Health in the Lao Peoples Democratic Republic. ibid. ibid.
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Thomas, A. and Louangkhot, N. (2005). Study on Gender and Ethnic Issues that Affect the Knowledge and Use of Reproductive Health Services in Six Ethnic Villages of Lao PDR. UNFPA, Lao Committee for Planning and Investment, and the National University of Laos, p. 38. Lyttleton, C. and Sayanouso, D. (2011). Cultural Reproduction and Minority Sexuality: Intimate Changes among Ethnic Akha in the Upper Mekong in Asian Studies Review, Vol 35. Primary Health Care Expansion Project (2005). Household Survey 2004. Vientiane, Lao PDR. Lao National Reproductive Health Survey (2005). Committee for Planning and Investment, National Statistics Centre, Vientiane, Lao PDR. Huijsmans, R. (2010). Migrating Children, Households and the Post-Socialist State: An Ethnographic Study of Migration and Non-Migration by Children and Youth in an Ethnic Lao Village. Durham University, p. 210. Gender Resource Information and Development Centre (2006). Lao PDR: Country Gender Profile, p. 27. Huijsmans, R. (2010). Migrating Children, Households, and the PostSocialist State. Durham University, p. 193. Lyttleton, C. (2005). Market Bound. Relocation and disjunction in Northwest Laos in Jatrana, S., Toyota, M. and Yeoh, B. Migration and Health in Asia, p.43; and Lyttleton, C. and Vorabouth, S. (2011). Trade Circles: Aspirations and Ethnicity in Commercial Sex in Laos. Culture, Health and Sexuality. Asian Development Bank (2009). Build It and They Will Come: Lessons From the Northern Economic Corridor for Mitigating HIV and Other Diseases. Phouxay, K and Tollefsen, A. (2010). Rural-Urban Migration, Economic Transition, and Status of Female Industrial Workers in Lao PDR in Population, Space and Place. John Wiley & Sons Ltd. ibid.
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ANNEX ONE: ENDNOTES
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Tan, D. (2006). Database Analysis of Women in Prostitution in Vientiane Capital (2005-2006). Phouxay, K. and Tollefsen, A. (2010). Rural-Urban Migration, Economic Transition, and Status of Female Industrial Workers in Lao PDR in Population, Space and Place. John Wiley & Sons Ltd. Sene-Asa, O. (2007). The Transition of Garment Factory Girls into Prostitution in Laos. AFESIP, p. 21. ibid., p. 22. Phouxay, K. and Tollefsen, A. (2010). Rural-Urban Migration, Economic Transition, and Status of Female Industrial Workers in Lao PDR in Population, Space and Place. John Wiley & Sons Ltd. Burnet Institute (2008). Young Womens Sexual Behaviour Study Vientiane Capital. Burnet Institute, Department of Health and UNFPA. Kemp, M. (undated). Report on a Scoping Study to Consider Workers Knowledge of Labour Rights in Vientiane City and Savannakhet Province. APHEDA. Garraghan, T.A. (2009). Just Beginning: A Qualitative Baseline Analysis of the Risk of Abuse and Exploitation of Sex Workers in Vientiane Capital and Subsequent Access to Legal Services, CARE, p. 8. Informed discussion with Suzie Albone, CARE and T.A. Garraghan, UNFPA. Webber, G. and Spitzer, D. (2010). Sexual and Reproductive Health Issues Facing Southeast Asian Beer Promoters: a Qualitative Pilot Study. BMC Public Health, 2010. http://www.biomedcentral.com/1471-2458/10/389 Tan, Danielle (2005-2006). Database Analysis of Women in Prostitution in Vientiane Capital, p. 7. Garraghan, T.A. (2009). Just Beginning: A Qualitative Baseline Analysis of the Risk of Abuse and Exploitation of Sex Workers in Vientiane Capital and Subsequent Access to Legal Services, CARE, p. 15.
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Tan, D. (2005-2006). Database Analysis of Women in Prostitution in Vientiane Capital. Burnet Institute (2008). Young Womens Sexual Behaviour Study Vientiane Capital. Burnet Institute, Department of Health and UNFPA, p. 40. Chamberlain, J. and Albone, S. personal communication. PSI (undated). HIV Prevention Behaviour TRAC Study Among Lao Female Sex Workers. United Nations Population Fund (2008). Assessment of the Referral and Counseling Network Youth-Friendly Services, p. 51. United Nations Population Fund (2008). Assessment of the Referral and Counseling Network Youth-Friendly Services, p. 53. ibid., p. 7. Rigg, J. (2007). Moving Lives: Migration and Livelihoods in the Lao PDR, in Population, Space and Place. John Wiley & Sons Ltd, p. 169. Phouxay, K., Malmberg, G. and Tollefsen, A. (2010). Internal Migration and Socio-Economic Change in Laos in Migration Letters, Volume 7, pp 194-204. Chamberlain, J. (2000). HIV Vulnerability and Population Mobility in the Northern Provinces of the Lao Peoples Democratic Republic, UNDP, p. 25. Rigg, J. (2007). Moving Lives: Migration and Livelihoods in the Lao PDR in Population, Space and Place. John Wiley & Sons. ibid. Phouxay, K. and Tollefsen, A. (2010). Rural-Urban Migration, Economic Transition, and Status of Female Industrial Workers in Lao PDR in Population, Space and Place. John Wiley & Sons Ltd. ibid.
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ANNEX ONE: ENDNOTES
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Doussantousse, S., Sakounnavong, B. and Patterson, I. (2011). Social Change in Luang Namtha Province, Lao PDR: An Expanding Sexual Economy Along National Route 3, (for forthcoming publication in Health, Culture and Sexuality). Lyttleton, C. and Vorabouth, S. (2011). Trade Circles: Aspirations and Ethnicity in Commercial Sex in Laos in Culture, Health and Sexuality. Phouxay, K. and Tollefsen, A. (2010). Rural-Urban Migration, Economic Transition, and Status of Female Industrial Workers in Lao PDR in Population, Space and Place. John Wiley & Sons Ltd. Garraghan, T.A. (2009). Just Beginning: A Qualitative Baseline Analysis of the Risk of Abuse and Exploitation of Sex Workers in Vientiane Capital and Subsequent Access to Legal Services. CARE, p. 57. ibid., p. 69. Lyttleton, C. and Vorabouth, S. (2011). Trade Circles: Aspirations and Ethnicity in Commercial Sex in Laos in Culture, Health and Sexuality. Chamberlain, J. (2000). HIV Vulnerability and Population Mobility in the Northern Provinces of the Lao Peoples Democratic Republic, UNDP, p. 25. ibid., p. 25. Lyttleton, C. (2004). Watermelons, Bars and Trucks: Dangerous Intersections in Northwest Lao PDR, p. 80. Chamberlain, J. (2000). HIV Vulnerability and Population Mobility in the Northern Provinces of the Lao Peoples Democratic Republic. UNDP, p. 17. Lyttleton, C. and Vorabouth, S. (2011). Trade Circles: Aspirations and Ethnicity in Commercial Sex in Laos in Culture, Health and Sexuality. ibid. Lyttleton, C. (2005). Market Bound. Relocation and Disjunction in Northwest Laos in Jatrana, S., Toyota, M. and Yeoh, B. Migration and Health in Asia, p.43.
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Lyttleton, C. and Sayanouso, D. (2011). Cultural Reproduction and Minority Sexuality: Intimate Changes among Ethnic Akha in the Upper Mekong in Asian Studies Review, Vol 35. ibid., p. 73. PSI (2008). Second Generation Surveillance CHAS, powerpoint presentation. Lyttleton, C. and Sayanouso, D. (2011). Cultural Reproduction and Minority Sexuality: Intimate Changes among Ethnic Akha in the Upper Mekong, in Asian Studies Review, Vol 35. Thomas, A. and Louangkhot, N. (2005). Study on Gender and Ethnic Issues that Affect the Knowledge and Use of Reproductive Health Services in Six Ethnic Villages of Lao PDR. UNFPA, Lao Committee for Planning and Investment and the National University of Laos, p. 12. Rigg, J. (2007). Moving Lives: Migration and Livelihoods in the Lao PDR in Population, Space and Place. John Wiley & Sons Ltd, p. 171. Phouxay, K. and Tollefsen, A. (2010). Rural-Urban Migration, Economic Transition, and Status of Female Industrial Workers in Lao PDR in Population, Space and Place. John Wiley & Sons Ltd. ibid. ibid. Phouxay, K. and Tollefsen, A. (2010). Rural-Urban Migration, Economic Transition, and Status of Female Industrial Workers in Lao PDR in Population, Space and Place. John Wiley & Sons Ltd. ibid. Lyttleton, C. and Sayanouso, D. (2011). Cultural Reproduction and Minority Sexuality: Intimate Changes among Ethnic Akha in the Upper Mekong in Asian Studies Review, Vol 35.
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ANNEX ONE: ENDNOTES
95
Lyttleton, C. and Vorabouth, S. (2010). Trade Circles: Aspirations and ethnicity in commercial sex in Laos. Culture, Health and Sexuality. Lyttleton, C. and Sayanouso, D. (2011). Cultural Reproduction and Minority Sexuality: Intimate Changes among Ethnic Akha in the Upper Mekong, Asian Studies Review, Vol 35. Damrong, T. (2005). Being Khamu: My Village, My Life. Bangkok: Matichon Press in Lyttleton, C. and Vorabouth, S. (2011). Trade Circles: Aspirations and Ethnicity in Commercial Sex in Laos in Culture, Health and Sexuality. PSI (2008). Second Generation Surveillance CHAS, powerpoint presentation, p. 7. Burnet Institute (2008). Young Womens Sexual Behaviour Study Vientiane Capital. Burnet Institute, Department of Health and UNFPA, p. 23. Garraghan, T.A. (2009). Just Beginning: A Qualitative Baseline Analysis of the Risk of Abuse and Exploitation of Sex Workers in Vientiane Capital and Subsequent Access to Legal Services. CARE, p. 15. ibid., p. 51. ibid., p. 77. Burnet Institute (2008). Young Womens Sexual Behaviour Study Vientiane Capital. Burnet Institute, Department of Health and UNFPA, p. 30. UN Country Team (2009). Brief for the Committee on the Elimination of All Forms of Discrimination Against Women by the United Nations Country Team in Lao PDR. Not for distribution, p. 42. Burnet Institute (2008). Young Womens Sexual Behaviour Study Vientiane Capital. Burnet Institute, Department of Health and UNFPA, p.31. Asian Development Bank (2009). Build It and They Will Come: Lessons From the Northern Economic Corridor for Mitigating HIV and Other Diseases.
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PSI (undated). HIV Prevention Behaviour TRAC Study Amoung Lao Female Sex Workers, p. 5. Doussantousse, S., Sakounnavong, B. and Patterson, I. (2011). Social Change in Luang Namtha Province, Lao PDR: An Expanding Sexual Economy Along National Route 3, (for forthcoming publication in Health, Culture and Sexuality). Burnet Institute (2008). Young Womens Sexual Behaviour Study Vientiane Capital. Burnet Institute, Department of Health and UNFPA, p.35. UNFPA (2008). Assessment of the Referral and Counseling Network YouthFriendly Services, p. 7. Albone, C. (CARE), Khounnauvong, B. (Gender and Development Group), and Grey, R. (PSI). Rigg, J. (2007). Moving Lives: Migration and Livelihoods in the Lao PDR in Population, Space and Place. John Wiley & Sons Ltd, p. 173. Tan, D. (2005-2006). Database Analysis of Women in Prostitution in Vientiane Capital, p. 8. Lyttleton, C. and Vorabouth, S. (2011). Trade Circles: Aspirations and Ethnicity in Commercial Sex in Laos in Culture, Health and Sexuality. Doussantousse, S. (2006). Migration of Children and Youth from Savannakhet Province, Laos to Thailand. World Vision. Phouxay, K. and Tollefsen, A. (2010). Rural-Urban Migration, Economic Transition, and Status of Female Industrial Workers in Lao PDR in Population, Space and Place. John Wiley & Sons Ltd. Phouxay, K. and Tollefsen, A. (2010). Rural-Urban Migration, Economic Transition, and Status of Female Industrial Workers in Lao PDR in Population, Space and Place. John Wiley & Sons Ltd. ibid.
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ANNEX ONE: ENDNOTES
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Webber, G. and Spitzer, D. (2010). Sexual and Reproductive Health Issues Facing Southeast Asian Beer Promoters: A Qualitative Pilot Study. BMC Public Health 2010. http://www.biomedcentral.com/1471-2458/10/389 Asian Development Bank (2009). Build It and They Will Come: Lessons from the Northern Economic Corridor for Mitigating HIV and Other Diseases. ibid.
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ANNEX TWO
People Interviewed
Robert Gray, Population Services International Suzie Albone, CARE Wannee Kunchornaratana, IOM Julie Crowe, UNIAP Margrethe Volden, Norwegian Church Aid John Reinstein, Save the Children Jim Chamberlain, independent researcher Mariolien Coren, ex-UNFPA staff member Boutsady Khounnauvong, Gender and Development Group Tingthong Phetsavong, UNIFEM Ketsone, Friends International Vonemaly Mongnomek, Acting for Women in Distressing Circumstance Philippa Sackett, Burnett Institute Chou Phayvieng Philakone, Family Health International TA Garraghan, Viengthong Manivone, UNFPA Mizuho Okimoto-Kaewtathip, Amy Delneuville, Victoria Juat, UNICEF
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ANNEX TWO: PEOPLE INTERVIEWED
ANNEX THREE
Overview from four Mekong country reviews

The following is a summary overview of the analysis presented in a series of four literature reviews that the United Nations Population Fund (UNFPA) commissioned to identify socio-cultural factors that affect the sexual and reproductive health of female migrants. The reviews encompassed looking at research, study reports and other available documents, mainly from the past decade, on internal migrants in Cambodia, Lao Peoples Democratic Republic and Viet Nam, and international migrants from Myanmar in Thailand. The reviews were premised on the assumption that socio-cultural factors impact on the potential of female migrants to access sexual and reproductive health information and services and protection from violence. The consultants sought to identify factors enabling access to information and services, as well as examples of good intervention models that might be replicated or scaled up. Potential barriers to access of reproductive health services by female migrants were also described. In the four countries included in the literature review, the majority of migrant women were found to be working in factories, the entertainment sector and domestic work. Almost all the literature available focused on the first two sectors, with no studies identified that looked specifically at the situation of domestic workers. Interviews with researchers, relevant staff from government institutions, United Nations agencies and non-governmental organizations, provided supplementary information on research, programmes and interventions addressing the sexual and reproductive health of migrant women. Migration in South-East Asia Labour migration grew dramatically in the early 1990s in South-East Asia, with Thailand becoming the main recipient
59
of migrants from other countries in the Mekong region. An estimated 1.8-3 million documented and undocumented migrants from neighbouring countries live in Thailand. Internal migration, however, dominates the flows of people within the region, despite the increasing movements of international migrants. At national level, internal migration rates vary significantly across provinces. Generally, there are few restrictions on intra-regional migration in the Mekong region and simultaneously there are few initiatives to facilitate safe migration. Poverty and the inability for rural economies to sustain themselves have been identified as the main drivers of labour migration. Political factors are also a trigger in the case of some migrants coming from Myanmar to Thailand. Internal migration has increased significantly in Cambodia, Lao PDR and Viet Nam for several reasons, including poverty and limited employment prospects in rural communities. Such movements have also been influenced by increased opportunities to work in factories and entertainment sectors as national economies have opened up. Migration has grown more feminized in recent decades. In the Mekong region, a large proportion of migrants tend to be young, unmarried women who move without their families. Migration has lifted many women and their families out of poverty. But the absence of legal and institutional mechanisms to protect their rights shows that economic gains within the region have often not been matched by parallel advances in social protection. Migration for many women means working in precarious and dangerous jobs often characterized by low wages, poor work conditions and lacking employment benefits. Many migrant women lack awareness on how to protect their own rights, including the right to health care. Review findings The literature reviewed showed that many women migrants encountered institutional, legal, economic, social or cultural barriers in accessing public health services. They usually lacked access to reproductive health information and services in their work destinations, a situation which was exacerbated by the fact that low-skilled migrants tended to have low levels of education, with a small proportion having had no education at all.
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ANNEX THREE: OVERVIEW FROM FOUR MEKONG COUNTRY REVIEWS
Several socio-cultural factors were identified as barriers to sexual and reproductive health information and services. For example, where women did not speak the same language as those in their migration destinations, language barriers were an important factor hindering access to relevant and timely health information and services. Unequal gender relations affected health-seeking behaviour. For example, in the countries reviewed, women were found to hold back on making decisions related to their sexual and reproductive health protection in deference to men. Young women were especially vulnerable to health risks because of their fear of it being found out that they were sexually active before marriage. Health service providers were reported to have prejudicial views of migrant women as not respectable and, in many cases, associated with sex work. Among migrants, therefore, there remained a strong preference for seeking traditional practitioners, private services, or over the counter medicine, rather than seeking treatment from public health facilities. In all four countries reviewed, significant numbers of unwanted pregnancies and unsafe abortions were reported. Belief in traditional explanations regarding health also sometimes served as barriers to understanding the seriousness of medical conditions and the necessity to seek immediate treatment. Cultural values such as preservation of face were found to have a significant impact on health-seeking behaviour. The fear of being stigmatized as an individual who deviates from societal norms was strong. This finding was closely associated with gender norms ascribed to women, namely that they should remain good women, sexually inactive before marriage. In spite of these expectations, in the role of economic provider many women were encouraged to seek employment away from home, often far from the security of traditional norms and support mechanisms. Nonetheless, community, and in particular the role of social networks, was found to be a critical factor influencing women migrants in general, including their sexual and reproductive health behaviour and, possibly, their health care choices. There were substantial quantitative and qualitative studies conducted on broader migration issues in three of the four countries reviewed - Cambodia, Thailand and Viet Nam - but links between the socio-cultural factors and sexual and reproductive health were rarely the specific focus of studies; such a link remains poorly documented. There is a need for more systematic research on internal migration, especially examining the migration trajectory of internal migrants and the effects on sexual and reproductive health outcomes.
61
Ethnic women who, until recently, were isolated from most development initiatives, are becoming increasingly visible among migrant populations, particularly in Viet Nam and Lao PDR. The nexus between ethnic cultures, beliefs and practices with migration has barely been explored at all. The literature on the situation of migrant women in Lao PDR is very limited and, given the increase in internal migration, research on a range of issues related to migration would strengthen the existing information available. The literature review focused on female migrant workers. However, several of the reports noted the need for corresponding research in relation to male migrants, particularly because male perceptions, knowledge and behaviours are likely to have a significant impact on female migrants sexual and reproductive health behaviour and outcomes in destination communities. In all four countries, migrant workers social networks and relationships formed in destination communities were found to have an important role in influencing their decision making and choices in all aspects of their lives. In most contexts such networks include male migrants, as well as men in destination communities. Socio-cultural factors impacting on male knowledge, attitudes and practice in the realm of sexual and reproductive health, and the links of this with women migrants health is thus deserving of greater investigation. The available research and reports of interventions reflected a focus almost entirely on sexually transmitted infections (STIs) and HIV prevention among migrant women, suggesting that priorities have corresponded to national concerns about the spread of HIV and AIDs in the region. The report of the AIDS Commission on Asia in 2008 clearly identified that HIV transmission in Asia was primarily among high-risk groups - sex workers, men who have sex with men, and intravenous drug users - some of whom may be migrants. Although some migrant women engaged in sex work (either directly in commercial establishments, or as a side-line to supplement their income), the majority of migrants were employed in low-risk occupations, such as factory work and domestic work. However the high mobility between employment sectors indicates that, potentially at least, the sexual and reproductive health of all migrant women is at risk. The very narrow clinical focus on STI and HIV prevention, by both governments and non-governmental providers, means that migrant womens other identities - as girlfriends, wives and mothers - has been neglected. Given that
62
a large proportion of migrant women appeared to be young and unmarried, and that societal norms and constraints are no longer necessarily applied or adhered to in migration destinations, potential needs for contraception must be addressed, particularly if unwanted pregnancies and unsafe abortions are to be avoided. To address the often high levels of unsafe abortion, emergency contraception should be added to the contraceptive mix in each country if not yet available. In Viet Nam and Thailand, significant numbers of the surveyed migrant women were also married and, in addition to contraceptive needs, they were in need of services including ante-natal and post-natal care and access to assisted deliveries and emergency obstetric care. Further research should be conducted to address the broader aspects of reproductive health and associated socio-cultural factors among these women. Additionally, although a number of the documents reviewed referred to the violence experienced by some migrant women - especially during the migration process and for those engaged in the entertainment and sex industries - there were few projects or programme interventions identified that aimed at protecting them from violence and addressing their right to access related support services. Several successful interventions to address the sexual and reproductive health needs of migrant women were documented. For example, to address the different language needs among migrant women from Myanmar in Thailand, information and educational materials were developed in the languages of the migrants and, in some locations, systems were established for bi-lingual migrant health workers and volunteers to accompany migrant women to public health services. Health clinics, including mobile clinics and drop-in centres in migrant communities, and clinics providing migrantfriendly services, including referral and counselling, have been successfully established in Thailand for migrants from Myanmar. In all four countries reviewed, peer educators were recruited and trained to work with migrant women, usually in their places of employment, and most often in work related to the entertainment industry where women frequently engaged in commercial or transactional sex. This approach was widely regarded as successful although often challenging due to the high mobility of migrants. Information, communication and education materials specifically targeting migrant women, which incorporate popular local beliefs, and which address relevant issues, were also noted as successful initiatives.
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Recommendations Given the general lack of regulatory systems in place to protect migrant workers, and insurance schemes to ensure their access to health services, a number of recommendations emerged from the reviews. A key identified need was for increased advocacy among policy-makers to ensure that migrant rights are included in all relevant national policies, and that service provision addresses their broad reproductive health needs. Recommendations were made that employers of migrant women, particularly factory owners and those involved in entertainment sector establishments, should promote reproductive health information through the workplace, using peer education strategies. Factory owners should make services available on site, or create time when staff can access external services during work hours without docking their pay. Health service providers would benefit from being trained in client-friendly service provision to ensure, in particular, that marginalized migrant women such as unmarried women, those engaging in sex work, and those from ethnic communities - are not discriminated against. This would entail strengthening the capacity of health providers to better understand socio-cultural influences on sexual and reproductive health, and the way gender norms affect healthseeking behaviour and the choices of female migrants. Increased attention should be paid to promoting behaviour-change communication strategies, and information and education materials, that respond directly to female migrants health vulnerabilities, and that are presented in a language and format that suits their levels of education, existing knowledge and preferences. A shift from a purely biomedical approach focusing on STI and HIV prevention towards a holistic approach that addresses the full range of migrant womens reproductive, and other, health needs, in non-discriminatory settings, would likely encourage more women to use available services. In addition, women migrants themselves need to be supported and empowered to advocate for and claim their own rights to health care and health protection. Migrant associations and NGOs could facilitate migrant women to set up support networks and groups to discuss issues related to migration, including sexual and reproductive health, and violence. The Thailand and Viet Nam reviews provide examples of such initiatives.
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Work could also be done with workers and employers organisations, and law enforcement officers to facilitate women migrants access to justice and to ensure that rights violations are addressed. In all four countries, this would entail considerable capacity strengthening, given the vested interests that some law enforcement officers are reported to have in colluding with negligent employers and other intermediaries involved in the migration process. Lastly, in some contexts, and because of their influence at the community level, religious leaders capacity could be strengthened to support migrant womens rights.
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UNFPA, the United Nations Population Fund, is an international development agency that promotes the right of every woman, man and child to enjoy a life of health and equal opportunity. UNFPA supports countries in using population data for policies and programmes to reduce poverty and to ensure that every pregnancy is wanted, every birth is safe, every young person is free of HIV, and every girl and woman is treated with dignity and respect. UNFPA - because everyone counts.
UNFPA Lao PDR Ban Phonesavanh Tai Sisattanack District Vientiane, Lao PDR http://lao.unfpa.org

Socio-Cultural Influences On The Reproductive Health of Migrant Women (A Review of Literature in Lao PDR)

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SOCIO-CULTURAL INFLUENCES on the reproductive health of migrant women

A REVIEW OF LITERATURE IN LAO PDR

SOCIO-CULTURAL INFLUENCES on the reproductive health of migrant women

SOCIO-CULTURAL INFLUENCES ON THE REPRODUCTIVE HEALTH OF MIGRANT WOMEN

Dr. Esther Muia UNFPA Representative in the Lao PDR

SOCIO-CULTURAL INFLUENCES ON THE REPRODUCTIVE HEALTH OF MIGRANT WOMEN

William A. Ryan / UNFPA APRO

SOCIO-CULTURAL INFLUENCES ON THE REPRODUCTIVE HEALTH OF MIGRANT WOMEN

SOCIO-CULTURAL INFLUENCES ON THE REPRODUCTIVE HEALTH OF MIGRANT WOMEN

SOCIO-CULTURAL INFLUENCES ON THE REPRODUCTIVE HEALTH OF MIGRANT WOMEN

William A. Ryan / UNFPA APRO

SOCIO-CULTURAL INFLUENCES ON THE REPRODUCTIVE HEALTH OF MIGRANT WOMEN

CHAPTER ONE: INTRODUCTION

William A. Ryan / UNFPA APRO

SOCIO-CULTURAL INFLUENCES ON THE REPRODUCTIVE HEALTH OF MIGRANT WOMEN

CHAPTER TWO: BACKGROUND

SOCIO-CULTURAL INFLUENCES ON THE REPRODUCTIVE HEALTH OF MIGRANT WOMEN

CHAPTER TWO: BACKGROUND

SOCIO-CULTURAL INFLUENCES ON THE REPRODUCTIVE HEALTH OF MIGRANT WOMEN

CHAPTER TWO: BACKGROUND

UNFPA Lao PDR

SOCIO-CULTURAL INFLUENCES ON THE REPRODUCTIVE HEALTH OF MIGRANT WOMEN

CHAPTER TWO: BACKGROUND

SOCIO-CULTURAL INFLUENCES ON THE REPRODUCTIVE HEALTH OF MIGRANT WOMEN

CHAPTER TWO: BACKGROUND

SOCIO-CULTURAL INFLUENCES ON THE REPRODUCTIVE HEALTH OF MIGRANT WOMEN

CHAPTER TWO: BACKGROUND

William A. Ryan / UNFPA APRO

SOCIO-CULTURAL INFLUENCES ON THE REPRODUCTIVE HEALTH OF MIGRANT WOMEN

CHAPTER TWO: BACKGROUND

SOCIO-CULTURAL INFLUENCES ON THE REPRODUCTIVE HEALTH OF MIGRANT WOMEN

CHAPTER TWO: BACKGROUND

Family Health International (FHI) - a global health and development

Vientiane Youth Centre for Health and Development, managed by the

SOCIO-CULTURAL INFLUENCES ON THE REPRODUCTIVE HEALTH OF MIGRANT WOMEN

CARE International - an NGO working to end poverty through

CHAPTER TWO: BACKGROUND

Prince Roy / flickr

SOCIO-CULTURAL INFLUENCES ON THE REPRODUCTIVE HEALTH OF MIGRANT WOMEN

CHAPTER THREE: REVIEW FINDINGS

SOCIO-CULTURAL INFLUENCES ON THE REPRODUCTIVE HEALTH OF MIGRANT WOMEN

CHAPTER THREE: REVIEW FINDINGS

SOCIO-CULTURAL INFLUENCES ON THE REPRODUCTIVE HEALTH OF MIGRANT WOMEN

CHAPTER THREE: REVIEW FINDINGS

SOCIO-CULTURAL INFLUENCES ON THE REPRODUCTIVE HEALTH OF MIGRANT WOMEN

CHAPTER THREE: REVIEW FINDINGS

SOCIO-CULTURAL INFLUENCES ON THE REPRODUCTIVE HEALTH OF MIGRANT WOMEN

CHAPTER THREE: REVIEW FINDINGS

CHAPTER THREE: REVIEW FINDINGS

SOCIO-CULTURAL INFLUENCES ON THE REPRODUCTIVE HEALTH OF MIGRANT WOMEN

CHAPTER THREE: REVIEW FINDINGS

SOCIO-CULTURAL INFLUENCES ON THE REPRODUCTIVE HEALTH OF MIGRANT WOMEN

CHAPTER THREE: REVIEW FINDINGS

Strengths and Gaps

SOCIO-CULTURAL INFLUENCES ON THE REPRODUCTIVE HEALTH OF MIGRANT WOMEN

CHAPTER FOUR: STRENGTHS AND GAPS

SOCIO-CULTURAL INFLUENCES ON THE REPRODUCTIVE HEALTH OF MIGRANT WOMEN

Conclusions and Recommendations

Lao PDR is facing rapid social change due to development

William A. Ryan / UNFPA APRO

SOCIO-CULTURAL INFLUENCES ON THE REPRODUCTIVE HEALTH OF MIGRANT WOMEN

Ethnic groups are particularly affected by these social changes due to

Many young women voluntarily leave home as a rite of passage, driven