Birth control, contraception and abortion in Gaza
Hélène Servel investigated the sociocultural factors linked to unwanted births, contraception use and abortions in the Gaza strip; a territory that's been under complete blockade for 10 years.
Taking into account the high population density and fertility rate, and the daily hardship faced by residents, Servel asked how are these practices are perceived by the population; how social pressures restrict their usage, and what impact they have on Gaza's demographic.
With more than 1,881,000 people living on just 365 km2 (or 5,000 inhabitants per km2), the changing demographic is a crucial issue for Gaza. The fertility rate was about 5.1 per woman in 2010, when that of the neighbouring West Bank was "only" 4.8. Despite the major humanitarian issue this presents, especially considering the 10 year long blockade, birth control is rarely mentioned.
Birth rate and fertility have always been considered political matters by the Palestinian authorities, especially during Intifada periods, when the war against Israel was also fought through population growth. In the context of war, or at least a context of sustained violence, more children meant more participants in the national struggle for liberation.
Breed more fighters?
In the last few decades, a successful communication campaign has been used by Palestinian authorities to promote the model of a smaller family, one in which the parents are free to decide on the number and frequency of births.
|Birth rate and fertility have always been considered political matters by the Palestinian authorities|
Consequently, the use of contraception has been promoted by institutions such as the United Nations Population Fund (UNFPA) and the The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA).
However, it's been limited to married couples, usually only after they've already had a couple of children.
The occupation and the complete blockade imposed on the Gaza strip remain decisive factors for decisions concerning maternity. In periods of conflicts, especially Intifadas, the tendency was to breed more children to provide more fighters and replace the martyrs.
Today however, the toxic economic, social and humanitarian situation is driving couples to reduce the size of their family, not only for financial reasons but also to secure a better education for their children.
|The toxic economic, social and humanitarian situation is driving couples to reduce the size of their family|
Hamas' policies follow Islamic law, whose religious and social principles impact daily life. Consequently, even though contraception is accepted as a way of controlling the frequency of births and protect a woman's health (tanzim al-nasl), it is still prohibited as way of avoiding them (tahdid al-nasl).
Contraceptive techniques have been allowed for about 40 years, but this excludes irreversible procedures such as tying the fallopian tube. UNRWA first introduced family planning programs in 1993 and in 1997 the Health Department followed suit. The Palestinian Authority (PA) has considered fertility rate as a matter of national strategy since 1994.
Recently, discourse and behaviours have seemed to fall in line with the latest PA guidelines on restricted families. Most women appear convinced of the benefits and advantages of contraceptive methods, seeing how they impact positively on the mother's and children's health, but also on her independence and the organisation of hers and her children's lives.
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In fact, in Palestine, less than one percent of women who use no contraceptive method claim they abstain for religious reasons.
On the other hand, even though social and religious rules forbid any restriction on the number of children, some educated women covertly admit that life in Gaza compels them to wish for only two or three, as this allows them to feed them decently and secure a better quality of education.
Access to information and contraceptives remains unequal
Access to contraception is narrowly linked to how information on the subject is broadcast. Even though the authorities created an array of communication tools in 1990s, including pamphlets, posters, TV and radio ads, and awareness campaigns, communication on these matters remains very limited.
However, as early as 2000, over 90 percent of married Palestinian women were aware of at least one contraceptive method. This number rose to 99 percent in 2014, mirroring a relatively high rate of use of contraceptives.
|In reality, information is shared through informal, personal channels of communication|
In reality, information is shared through informal, personal channels of communication. Discussions between women turn out to have much greater impact than a visit to the doctor, especially for young women who receive no official information on the subject - so as not "encourage" sexual intercourse outside of wedlock.
Doctors will only consent to discuss women's bodies with them after they're married, and sometimes only after one or two pregnancies and the staff in charge of prevention are not adequately trained. As for men, they appear unconcerned by the matter, and prefer seeking their own information.
Firstly, access to information is dependent on a person's administrative status. In practice, 72 percent of Gaza's population are refugees enrolled with UNRWA, which grants them access to its free infrastructures and services, including those related to contraception. The remaining 28 percent are "citizens", meaning originally from the pre-1948 Gaza strip area, and must use the public health services, which are neither free, nor such good quality.
These two different statuses explains the dual standards of the Palestinian health system, revealing the underlying economic inequalities regarding access to contraception. According to a 2012 report, all of the UNRWA-run 21 centres in the Gaza strip provided family planning services, as opposed to only 16 out 56 of the government-run centres.
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Secondly, inequalities in the access to information follow the urban-rural divide: Urban zones have better coverage than rural areas, which are more marginalised and isolated.
Access is also implicitly restricted to married women, although over the last two decades, proof of marital status has no longer been a requirement.
|Doctors will only consent to discuss women's bodies with them after they're married|
Although globally robust across the Gaza strip, contraceptive supplies are also subject to shortages, especially in times of crisis. The UNFPA - the sole provider of contraceptives for Palestine - has recently announced planned cuts in its budget in view of specifically reducing the funds directed to the Gaza strip from June 2017.
Although only partially documented now, these planned budget cuts might cause shortages. This threat to the right to contraception might be all the more disastrous as it would take place in a context of demographic and humanitarian crisis. This also reveals the dangerous dependence of the Gaza health system on international aid when it comes to equipment supplies, medicines, infrastructures and care.
The religious dimension
The issue of abortion is highly sensitive in Gaza, as in the 80s and 90s, the conflict with Israel extended its impact to babies in cradles, when a "population war" broke out.
"Replacement fertility" became a common idea, aiming to "compensate for the loss of martyrs" and a much larger proportion of refugee women in Gaza (46.6 percent) are believed to want at least six children, compared to 26.6 percent of women in the Gaza strip.
This "political aspect of fertility" is no longer relevant. Outside of the political and historical context, abortion remains taboo, and forbidden chiefly for religious reasons. "There is no logical reason for abortion", claims Kefah Al-Rantisi, a spokeswoman for the Ministry of Religious Affairs.
Only a few exceptional circumstances can justify the procedure, such as when there's a threat to the mother or the child's life. But despite the apparent clarity of the legal guidelines, they are in practice interpreted and enforced through the consultation of a mufti and the diagnosis of two doctors. Final say is left to the interpretation, social position and reputation of these men.
|'Replacement fertility' became a common idea, aiming to 'compensate for the loss of martyrs'|
In the end, such opaque health measures related to unwanted pregnancies and abortions is no doubt a factor that makes it difficult to broach the more taboo questions.
Considered overall as incompatible with sociocultural and religious norms, abortion is thus judged negatively by most women. And yet, many of them do in fact resort to the practice and even justify it: It's a matter of safeguarding the mother's physical and psychological health, it's to guarantee a better education for the children, it's because the pregnancy was too early or too late, it's because the marriage is rocky…
Other factors, not as often mentioned by women, do matter too. Zeinab Al-Ghunaimi, a Gaza lawyer and head of a research and legal advice centre for women in Gaza City explains: "Incestuous relations and poverty are situations which influence the decision to abort, but are less visible because they happen over a longer period of time and are the consequences of a deeply-rooted economic and social domination."
All this makes data difficult to obtain, and the few figures that are available from Médecins du Monde show 5,996 abortions in 2011, and 6,983 in 2012. And yet, many testimonies reveal situations where an unwanted pregnancy led to an abortion: If this is not always possible because of the harsh restrictions on women, it does remain the most frequent situation.
A path with many obstacles
Women who wish to terminate their pregnancy must observe the social norms, or fight against a succession of men who stand in the way of their decision. Most health professionals try to dissuade them, invoking moral reasons and thus playing the role of guardians of social norms.
|Final say is left to the interpretation, social position and reputation of these men|
In parallel, there is a web of relations who weigh in on the decision. The woman's family and the mother-in-law play a crucial role, from logistical and psychological support to reprimand and moral disapproval.
As for the husbands, they sometimes want fewer children, and so might encourage the woman to abort, or even force her to.
Despite the official ban, private doctors do provide abortions, clandestinely and for a high fee (about US$400-US$500). A married woman can access an abortion if someone they know is a doctor, or if they have the money to pay for it.
In the words of a social worker from Gaza City, "If you have money, if you, or someone in your entourage is a doctor at the hospital, it's much easier for you to get an abortion at the hospital. 'Wasta' (nepotism) works for abortions too!" That's why a whole system based on clientelism can develop. The murky legislation allows social and economic inequalities to come to the surface.
In the context of humanitarian and political disaster, questions of reproductive and sexual health do not constitute a priority for the Gaza authorities. And yet, Gaza has become a virtual open-air prison due to the deterioration of its demographic situation, which the blockade imposed by the Israeli government has only made worse.
Of course the political context plays a crucial part, but the religious and social framework does not make it easy to address these questions, which are considered taboo.
Finally, because of the health system's dependence on international aid, the Gaza population is made even more vulnerable to the budget cuts planned by international organisations and to deteriorations of living conditions. As a consequence, demographic trends do not indicate any future slowing down in the birth rate.
Hélène Servel is a freelance journalist and student of political science and anthropology.
This is an edited translation of an article originally published by our partners at Orient XXI.