1The fertility of populations living in the Palestinian Territories remained exceptionally high for many years. Yet recent changes in their reproductive behaviours, and notably the much broader diffusion of contraception in the Territories than elsewhere in the region, raise questions about the factors driving fertility decline. In this article, Sarah Memmi and Annabel Desgrées Du Loû combine two types of data – a statistical survey conducted in 2006 and in-depth interviews with Palestinian couples – to analyse the role of conjugal relationships in determining contraceptive use. Three categories of couples are defined by establishing a typology of gender relations within the couple relative to fertility control. While for some sections of the population fertility behaviours are still structured by patriarchal gender norms, for others the couple is becoming a unit of dialogue and shared decision-making where contraceptive choices are made jointly.

2Palestinian fertility has often been described as a “demographic conundrum” (Pedersen et al., 2001). Indeed, despite a high level of education among both women and men (Giacaman and Johnson, 2002; Heiberg, 1993), a low infant mortality rate (Khawaja, 2004) and better access to contraception than in other countries of the region (Khawaja et al., 2009), the Palestinian fertility rate has long remained one of the highest in the world. Although fertility has fallen in recent years, it remains high: the total fertility rate (TFR) fell from 6.2 children per woman in 1990 to 4.1 in 2009 (PCBS, 2010), which is still above the regional average of 3.6 children per woman (Courbage and Todd, 2007). Moreover, having many children, especially sons (Abu Nahleh and Johnson, 2002; Kanaaneh, 2002; Memmi, 2012), remains a powerful social norm, despite a higher female educational level in Palestine than in neighbouring countries (Abdul Rahim et al., 2009).

3Several studies attribute the persistence of high fertility to the Israel-Palestine conflict (Della Pergola, 2001; Zimmerman et al., 2006), even referring to a “war of cradles” (Courbage and Todd, 2007): changing the demographic balance by having more children has long been seen as “a weapon against occupation” (Courbage, 1994; Peteet, 1991), or “an instrument of national liberation” (Giacaman et al., 1996). During the first Intifada (the Palestinian uprising between 1987 and 1993), fertility rose, including among the most educated women, who are highly politicized (Courbage, 1997).

4Before being mobilized politically, however, reproduction and contraception are a component of the conjugal relationship, and of the balance of power between the spouses. Control over reproduction is central to gender relations. For the anthropologist Françoise Héritier, men’s control over women’s fertility is the main instrument of male domination (Héritier, 1996). While studies of contraception traditionally focus on women, and most surveys of contraceptive practices only target female respondents, men are closely involved in controlling fertility (Oppenheim Mason and Taj, 1987). The contraceptive revolution that opened up access to medical contraceptive methods was initially perceived as a means for women to regain control over their fertility, but Nathalie Bajos and Michèle Ferrand argue that it has in fact reaffirmed the traditional gender system, in which female identity is based on motherhood (Bajos and Ferrand, 2005). Women thus continue to bear “primary responsibility” for pregnancy and contraception (Bajos and Ferrand, 2004; Bajos et al., 2002; Caselli et al., 2006). Men nevertheless play a crucial role at every stage in the reproductive process, as sexual partners and as holders of a large share of the decision-making power within the conjugal and family unit (Andro and Desgrées du Loû, 2009). So it is important to bear in mind the obvious fact that reproduction involves both partners, with each having a potential say in reproductive choices and practices (Andro, 2000). Family planning studies increasingly consider men’s as well as women’s attitudes to fertility control (Bankole, 1995; Duze and Mohammed, 2006; Ezeh, 1993; Kulczycki, 2008; Yang, 1993) and analyse reproductive practices not only at individual level but also at conjugal level (Andro and Hertrich, 2001; Bankole and Singh, 1998; Karra et al.,1997).

5To enhance our understanding of the factors behind the Palestinian “demographic conundrum”, we propose to explore birth control in the Palestinian Territories at conjugal level. How do married couples – the only legitimate framework for reproduction – manage fertility (i.e. family size) and contraception? To what extent do gender relations between spouses shape fertility control in a society that provides education for women but remains structured by a strong gender and generational hierarchy? Is family planning controlled by men, who exercise power in this politically charged sphere, or by women, because it concerns women’s bodies? We posit that it is the conjugal relationship and the gender relations between spouses that shape contraceptive history.

6Based on data from the Palestinian Family Health Survey, and on in-depth interviews with married Palestinians (men and women), we analyse the prevalence and determinants of contraceptive use in the Palestinian Territories, and the contraceptive methods employed. We explore how couples manage decisions about reproduction and birth control and how these modes of “conjugal organization” tie in with the gender roles upon which the conjugal relationship is constructed. Who decides, when is the decision made, and for which type of contraception?

I – Population and methods

7This research combines two approaches: a secondary analysis of the data from the Palestinian Family Health Survey to obtain quantitative information about the prevalence and determinants of contraceptive use in the Palestinian population; and an analysis of in-depth interviews of married men and women conducted specifically for this research project.

II – Prevalence and determinants of contraceptive practice in the Palestinian Territories

24The population surveyed in the PFHS is described in Appendix Table A.2. Almost all of the 4,486 women at risk of pregnancy surveyed in 2006 could read and write, but their levels of education varied widely: one-third had basic education, [12] one-third had primary education, and one-third had secondary or tertiary education. Almost nine out of ten women were homemakers, and seven out of ten had a husband who worked. More than half of the women surveyed belonged to the middle class and lived in an urban area. More than nine out of ten women were in a monogamous union. The average number of children per woman was 5.1.

1 – Widespread contraceptive use

25More than one woman in two reported that she or her husband was using contraception at the time of the survey in 2006; almost three-quarters of the women who used contraception said they used a medical method. The IUD accounts for half of contraceptive use, followed by the pill, withdrawal, the male condom, and lastly periodic abstinence (Table 1).

Table 1

Contraceptive use and indicators of conjugal relations with respect to fertility control (N = 4,486)^(a),(b),(c)

N Percentage of all women (N = 4,486) Percentage of women using contraception (N = 2,444) Contraceptive practice Using contraception at the time of the survey 2,444 54.5 100 Using a medical contraceptive method 1,763 39.3 72.1 of which: Pill 332 7.4 13.6 IUD 1,266 28.2 51.8 Injection 34 0.8 1.4 Implants 1 0.0 0.0 Vasectomy 1 0.0 0.0 Female sterilization 129 2.8 5.3 Using a non-medical contraceptive method 681 15.2 27.9 of which: Male condom 220 4.9 9.0 Periodic abstinence 168 3.7 6.9 Withdrawal 286 6.4 11.7 Female condom 7 0.2 0.3 Contraceptive decision-making in the couple(b) Wife decides 433 9.7 10.2 Husband decides 809 18.3 14.6 Couple decides together 3,186 72.0 75.2 Couple has discussed the desired number of children No 1,850 41.2 39.1 Yes 2,639 58.8 60.9 Husband’s fertility goals compared with wife’s(c) Husband wants same number of children as wife 2,105 51.6 51.6 Husband wants more children than wife 1,396 34.2 32.0 Husband wants fewer children than wife 582 14.3 16.4

Contraceptive use and indicators of conjugal relations with respect to fertility control (N = 4,486)^(a),(b),(c)

(a) Married women aged 15-54 who were not pregnant or menopausal at the time of the survey.
(b) Among the 4,428 women who answered this question.
(c) Among the 4,083 women who answered this question.

26Contraception is used by all types of Palestinian women, regardless of their own and their husband’s level of education (Table 2); even among the least educated women, 50% reported using contraception at the time of the survey. Working women tend to use contraception more, but the difference is not significant.

Table 2

Percentage of women who reported using contraception at the time of the survey by socio-demographic characteristics of the women and their husbands (bivariate and multivariate analysis, logistic regression)

Total Crude percentage p-value (bivariate) Adjusted odds ratio [95% CI] Overall 2,444 54.4 Woman’s age < 0.001 15-24 220 35.6 5.98 [3.53-10.11] 25-34 961 62.7 6.99 [4.58-10.72] 35-44 995 68.2 5.38 [3.94-7.36] 45+ (Ref.) 248 28.7 1 Woman’s educational level < 0.001 Basic (Ref.) 785 49.8 1 Primary 854 57.4 1.18 [0.97-1.45] Secondary 500 56.3 1.43 [1.12-1.84] Tertiary 305 57.1 1.23 [0.87-1.75] Couple’s employment status < 0.001 Only the husband works (Ref.) 2,010 62.2 1 Both spouses work 265 56.9 1.07 [1.03-1.67] Only the wife works 88 56.8 1.22 [0.77-1.93] Neither spouse works 64 25.5 0.57 [0.37-0.87] Length of the marriage < 0.001 Less than 10 years 571 46.9 1.19 [0.87-1.62] 10-19 years 1,121 67.8 1.57 [1.03-2.40] 20+ years (Ref.) 721 48.9 1 Type of union < 0.001 Polygamous (Ref.) 88 29.9 1 Monogamous 2,356 56.2 2.70 [1.84-3.95] Fertility intention < 0.001 Wants another child (Ref.) 975 45.8 1 Does not want any more children 1,282 71.0 3.65 [2.92-4.56] Number of liveborn sons < 0.001 0 (Ref.) 96 17.3 1 1-2 1,038 57.8 3.45 [2.48-4.49] 3+ 1,310 61.4 4.77 [3.26-5.84] Number of liveborn daughters < 0.001 0 (Ref.) 179 27.3 1 1-2 1,106 60.4 2.07 [1.45-2.96] 3+ 1,159 58.0 0.98 [0.78-1.18] Socioeconomic status < 0.001 Poor (Ref.) 395 47.8 1 Middle-class 1,499 54.4 1.53 [1.23-1.89] Affluent 550 60.8 1.85 [1.37-2.48] Region < 0.001 West Bank 1,392 60.7 2.23 [1.83-2.72] East Jerusalem 274 57.0 1.77 [1.33-2.36] Gaza Strip (Ref.) 778 45.5 1

Total Crude percentage p-value (bivariate) Adjusted odds ratio [95% CI] Couple has discussed desired number of children 0.002 No (Ref.) 956 51.7 1 Yes 1,488 56.4 1.06 [1.01-1.35] Husband’s fertility goals compared with wife’s < 0.001 Husband wants the same number of children as wife (Ref.) 1,177 55.9 1 Husband wants more children than wife 730 52.4 0.98 [0.82-1.16] Husband wants fewer children than wife 373 64.1 1.63 [1.28-2.09] Contraceptive decision-making in the couple < 0.001 Wife decides 249 57.5 0.75 [0.55-0.92] Husband decides 356 44.0 0.67 [0.58-0.87] Couple decides together (Ref.) 1,836 57.6 1

Percentage of women who reported using contraception at the time of the survey by socio-demographic characteristics of the women and their husbands (bivariate and multivariate analysis, logistic regression)

Note: The following variables were also introduced into the model but did not have a significant influence: man’s age and educational level, number of children, and place of residence (N = 4,486). The missing values for each variable were excluded from the analysis and are not represented in the table.

27Conversely, some groups clearly use contraception less: couples where neither spouse works; the poorest women; women who live in Gaza; and women in a polygamous union (Table 2).

2 – Is birth control influenced by a “reproductive contract”?

28The probability of using contraception is more than three times higher among women who already have at least one son than among women who have no sons (odds ratio (OR) = 3.45, Table 2). Among women with at least one daughter contraceptive use is only twice as high as among those with no daughters (OR = 2.07).

29Among women who have already used contraception, the mean number of children is 3.3 when they first start using contraception, [13] and the changes in contraceptive prevalence by number of children already born show that contraceptive use increases steadily with the number of children, to a maximum level after four children (Figure 1). [14] We observe a lag between the curves of women using contraception by the number of sons and by the number of daughters: women who have no sons or only one son use contraception less frequently than women who have no daughters or only one daughter.

Figure 1

Percentage of women who report using contraception by number of liveborn children and their sex

Percentage of women who report using contraception by number of liveborn children and their sex

30The breakdown by educational level (Figure 2) shows that these differences by sex of children already born are apparent at all educational levels up to secondary, but disappear among women who have tertiary education.

Figure 2

Percentage of women who report using contraception by number of liveborn children and by educational level

Percentage of women who report using contraception by number of liveborn children and by educational level

31Use of contraception starts late, after several children have already been born. It is subordinate to the ideal of many children, especially sons: the average desired number of children per woman is 4.9, including 2.7 sons. Even among the most educated women, ideal fertility is high: women who have tertiary education want an average of 4.4 children. One of our respondents with tertiary education explains the concept of an “ideal family size” of around four children:

32

I think the ideal is to have two children of each sex. I have two sons, so they can play together. My daughter often asks me for a sister to play with because she feels lonely. It would be nice to give her a little sister.

33Sex preference also persists among these highly educated women, since they report a slightly higher ideal number of sons than daughters: 2.4 sons compared with 2.05 daughters. Dana (woman, 39, two daughters, tertiary education, Ramallah, 2011) said she wanted a son in order “to feel complete”:

34

As an Arab woman, I have the idea that I need a son to feel “complete”. I also need a son to defend my daughters, so they have a brother to accompany them when they go out and make them feel protected. That’s important in our society and they need that.

35This reproductive norm may be imposed by the extended family, who put strong pressure on couples who have few children or no sons. Fatima (woman, 25, one daughter) explains that her mother-in-law reminds her every time she visits that she can’t have “just one child, especially a daughter”. If a couple follows its own desire for a small family, it often comes at the price of conflict with the family.

36Regardless of men’s and women’s educational levels, the Palestinian reproductive norm, i.e. socially valued fertility, is to have many children. To comply with the norm, it is as if Palestinians had to fulfil a “reproductive contract” of four children or more, with at least two sons.

III – Conjugal relations, gender relations and decision-making

39Our analysis of the determinants of contraceptive use has highlighted the importance of conjugal indicators in contraceptive use by Palestinians. The next step is to investigate how couples make decisions about birth control.

IV – Which couples use which type of contraception?

52Among women using contraception, three-quarters of the female respondents to the PFHS survey reported using a medical method, and one-quarter a nonmedical method. Analysis of the interviews reveals that the choice between medical and non-medical methods depends partly on the type of conjugal relations, in line with the three profiles described earlier.

53In traditional couples, the contraceptive method used at the beginning of their reproductive life is one that the man can control, i.e. a non-medical method (withdrawal or condom):

54

I don’t want us to use contraception. I can use my brain for that. I’m not an idiot. I can control myself. When I feel I’m about to climax, I withdraw, that’s all. I’m not stupid, I can manage it myself.

55As the head of the family, these men want to control fertility, and their authority prevails:

56

I decide because her whole life she has been used to obeying her father and her brother, I mean, “the men of the family”. Now I’m the man of the family, so I decide (…). I decided to use condoms, so I use condoms. That way, I also decide when we’ll have kids.

57When the reproductive contract has been fulfilled, the wife can make her own decisions about contraception, and there is more acceptance of medical methods because the number of children is no longer an issue:

58

He used to watch everything I did: where I went, what food shopping I did, how I dressed… and he decided on contraception and when we had children. He had the last word on everything, always (…) But now he has six healthy sons, so he is happy. He doesn’t need any more children, so I don’t think he cares whether I use contraception or not. I started using an IUD and he doesn’t ask questions.

59Non-medical methods are also used by egalitarian couples. However, this is not because the man wants to control fertility but rather because of wariness of medical methods; these men and women express a preference for a “natural” method and for “avoiding drugs”. Concerned to protect the woman’s health, they refuse to use IUDs or the pill, perceived as potentially harmful. They prefer methods they consider “natural” (male condom, periodic abstinence): [15]

60

I’m against the pill. I think it has a lot of side effects for women, so it’s better not to use it. We discussed it for a long time and decided to use condoms. They’re much better; at least they’re natural. I don’t have any problem with condoms and this way she won’t get stomach pain, headaches and all that.

61Periodic abstinence also requires accurate knowledge of the woman’s reproductive cycle, collaboration between spouses and significant female autonomy for effective control over the timing of intercourse (Johnson-Hanks, 2002).

62In couples with an intermediate profile, where controlling reproduction is the woman’s responsibility, medical contraception (mainly the IUD or pill) prescribed by a physician is always used first. If this method does not work (contraceptive failure or undesirable side effects), these couples may switch to non-medical methods, which require the husband’s collaboration. Some of these men appear reluctant to use condoms, fearing a loss of “male potency”: they feel that condoms restrict and interrupt the pleasure of sex and, by containing ejaculation, reduce the intensity of orgasm. To preserve their wife’s health, they prefer periodic abstinence or withdrawal, perceived as more “manly”. In any case, this contraceptive adjustment cannot take place without dialogue between husband and wife, even if they are not accustomed to discussing contraception.

63These qualitative observations are corroborated by the quantitative analysis. Table 3 shows the probabilities of using a non-medical method (condoms, withdrawal or periodic abstinence) or a medical method (pill, IUD, injection, implant, female sterilization, vasectomy) among women who use contraception. Two types of situations described earlier are found here too: first, non-medical methods are more frequently used by highly educated women in couples where both partners work and who take decisions about birth control with their partners; second, the probability of using a non-medical method is also higher among couples that have not yet had the number of children they want, among women who have fewer than three sons, among couples where the husband decides, and among couples where the husband wants fewer children than his wife. Non-medical contraception is thus used in two sets of circumstances: either out of concern for the woman’s health and with the agreement of both spouses, or when the man wants to control the couple’s fertility.

Table 3

Use of a non-medical method of contraception* by socio-demographic characteristics of the women and their husbands (bivariate and multivariate analysis, logistic regression) ^*

N % p-value (bivariate) Adjusted odds ratio [95% CI] Woman’s educational level 0.001 Basic (Ref.) 189 24.1 1 Primary 236 27.6 1.12 [0.87-1.45] Secondary 145 29.0 1.13 [0.83-1.52] Tertiary 111 36.4 1.46 [1.02-2.18] Couple’s employment status 0.020 Only the husband works (Ref.) 545 27.1 1 Both spouses work 82 40.9 1.75 [1.06-2.89] Only the wife works 36 30.9 1.01 [0.71-1.44] Neither spouse works 20 23.4 1.12 [0.59-2.09] Fertility intentions 0.016 Wants another child 311 31.9 1.12 [1.02-2.48] Does not want any more children (Ref.) 349 27.2 1 Number of liveborn sons < 0.001 None 44 45.8 2.03 [1.21-3.39] 1-2 318 30.6 1.29 [1.01-1.64] 3+ (Ref.) 319 24.4 1 Region 0.050 West Bank 369 26.5 1.32 [1.05-1.75] East Jerusalem 75 30.4 1.75 [1.37-1.88] Gaza Strip (Ref.) 237 25.3 1 Husband’s fertility goals compared with wife’s 0.038 Husband wants same number of children as wife (Ref.) 189 28.0 1 Husband wants more children than wife 122 25.9 1.02 [0.73-1.43] Husband wants fewer children than wife 330 32.7 1.21 [1.05-1.73] Contraceptive decision-making in the couple < 0.001 Wife decides (Ref.) 41 16.5 1 Husband decides 109 28.9 1.56 [1.34-2.85] Couple decides together 530 30.6 2.21 [1.43-3.43]

Use of a non-medical method of contraception* by socio-demographic characteristics of the women and their husbands (bivariate and multivariate analysis, logistic regression) ^*

* Condoms, periodic abstinence or withdrawal.
Coverage: Female contraceptive users.
Note: The following variables were also introduced into the model, but they did not have a significant impact: woman’s age, man’s educational level, length of the marriage, number of children, and communication between spouses, N = 2,444).

V – Discussion and conclusion

64The PFHS survey asked women but not men about family planning and birth control. The lack of data on sexual and reproductive health collected directly from men means that the quantitative analysis of the indicators of men’s fertility choices and contraceptive practices is based on what their wives said about them in the survey. This does not necessarily match the facts or actual male preferences and does not enable us to analyse accurately the expectations of both spouses in terms of fertility and birth control or the impact of those individual attitudes on contraceptive practice in general (Andro and Hertrich, 2001). The qualitative interviews of men and women shed more direct light on men’s attitudes to contraceptive choices and practices and enable us to compare them with women’s attitudes. The two approaches make different and complementary contributions: the quantitative data from the PFHS survey can be used for a cross-sectional analysis of the reported prevalence of contraceptive use and the factors involved in contraceptive choices at the time of the survey in a representative sample of the Palestinian population. The sample used for the qualitative interviews, although diverse, was not representative of the population, but the interviews enabled us to retrace contraceptive histories and to examine how gender relations between spouses have shaped those histories.

65The quantitative analysis confirms that birth control is widely practiced by married Palestinian couples. Indeed, 54% of the women surveyed reported using a contraceptive method, and the proportion reached 71% among women who did not want any more children. Contraceptive use in the Palestinian Territories is thus higher than the regional average of 46% (Roudi-Fahimi et al., 2012). At the same time, high fertility is still valued, even among the most educated people. While the educational level of Palestinian women is one of the determinants of fertility decline (Khawaja et al., 2009), most of the decline in the recent period has occurred among the least educated women: the total fertility rate fell from 7 to 5 children per woman between 1999 and 2006 among women with less than secondary education, but remained stable at around 4 children per woman among the most educated women (Khawaja et al., 2009; PCBS, 2006).

66We thus observe both high contraceptive use and still high fertility in the Palestinian Territories, because there is still strong social prestige attached to having many children, especially sons. Couples must fulfil a “reproductive contract” (at least three or four children, and sons), and this is a powerful norm even among the most educated women. Contraception is used relatively late in reproductive life in the Palestinian Territories, as in many developing countries (Ozalp et al., 1999). Contraceptive use increases with the number of liveborn children, reaching its maximum when women have four, with noteworthy differences by the sex of children already born: contraception is not regularly practised until the woman has had at least two sons. Similar links between the number and sex of children already born and contraception were identified in the previous decade in other countries of the sub-region, such as Jordan (Al-Oballi and Libbus, 2001) and Egypt, where a contraceptive peak is also observed when couples have three sons (Yount et al., 2000). Research conducted in India has also shown that the number of sons already born is a major determinant of contraceptive use, especially among the least educated women (Arokiasamy, 2002; Clark, 2000).

67Even among educated women, an emphasis on male offspring persists. In another analysis, we observed that the most educated women are also the most likely to use prenatal sex selection to ensure at least one male birth while having only two or three children (Memmi and Desgrées du Loû, 2014). In those educated couples, it was also the men who expressed the most distance from the pressure “to have sons”. This indicates that the social expectation of having sons is directed primarily at women, who are often blamed if there are no male offspring (Kanaaneh, 2002).

68The results also indicate that the poorest women and those who live in the Gaza Strip use contraception less frequently than other women. This is not due to problems of access to contraception, since several studies show that contraception is widely available in Gaza, the West Bank and East Jerusalem, regardless of socioeconomic status (Donati et al., 2000; Hammoudeh, 2012; Khawaja et al., 2009). Moreover, we do not observe any difference in contraceptive practice by place of residence (urban, rural or refugee camp). Lower use of contraception in these groups seems to reflect the social value attached to having even more children when unemployment is high, incomes are falling and starting a business is difficult, as some studies on Gaza have shown (Donati et al., 2000; Khawaja, 2000).

69It is highly likely that the value placed on fertility stems from the political situation in Palestine (Hanson et al., 2013; Kanaaneh, 2002; Khawaja, 2003; Khawaja et al., 2009), that prompted Youssef Courbage to coin the expression “political fertility” [16] (Courbage, 2011). The question of the political use of fertility did not really emerge in our interviews, except in the reports of two male respondents who were political activists. By contrast, the political dimension is a factor that explains the reluctance of institutional actors to introduce a national population policy.

70Although fertility choices are a political issue in the Palestinian setting, their implementation by couples is a matter for both husband and wife in the Palestinian Territories, as other studies have shown (DeRose et al., 2002; Dodoo, 1998; Kulczycki, 2008). Our research shows more specifically that the way in which men participate in birth control depends on gender relations within the couple. The type of conjugal relationship and the power structure between the spouses influence the choice of contraceptive method and the role of each partner in decisions about contraception over the reproductive life.

71In particular, attitudes to non-medical contraceptive methods (withdrawal, periodic abstinence and condoms) depend on the type of couple. While the use of non-medical contraception has been associated in the literature with a low educational level (Koc, 2000; Shapiro and Tambashe, 1994) and a lack of knowledge about “modern” medical methods (Goldberg and Toros, 1994), our results show a variety of situations. In the couples with unequal gender relations, which are also the least educated, men use non-medical methods such as withdrawal because they want to control fertility themselves; this behaviour is also observed in Turkey (Kulczycki, 2004). At the same time, the use of these methods by the most educated couples, with more egalitarian gender relations, can be attributed not to the man’s desire to manage the couple’s fertility, but to the couple’s mistrust of drugs. Similar observations have been made in other countries (Italy, Cambodia and Cameroon) (Gribaldo et al., 2009; Hukin, 2013; Johnson-Hanks, 2002), where non-medical methods are used to space births. In India, as in the Palestinian Territories, women use non-medical methods until the desired number of sons has been reached (Husain et al., 2012).

72The use of medical methods, which act upon the woman’s body but not the man’s [17] (pill, IUD, contraceptive injection, implants, female sterilization), may be perceived as a sign that women are controlling reproduction and therefore as a significant step forward in terms of gender equality (Héritier, 1996). Here too, our study reveals several situations: in couples with highly unequal gender relations, women may use hormonal methods that they control themselves, but only once the “reproductive contract” has been fulfilled. In other words, women only gain the autonomy to make decisions when fertility is no longer an issue. These findings tie in with the analysis by Nathalie Bajos and Michèle Ferrand in France, who showed that these types of methods contribute to the persistence of male domination in new forms (Bajos and Ferrand, 2004). According to those two authors, the use of medical methods consolidates the construction of female identity based on motherhood and thus reinforces gendered representations of the division of roles.

73Our findings call for prudence when interpreting the respective role of each spouse in controlling fertility based on the type of contraceptive method used (Oudshoorn, 1999). The same prudence is advisable when interpreting communication between spouses about family planning. Indeed, as already shown (Noumbissi and Sanderson, 1999; Oppenheim Mason and Taj, 1987), communication may be based on constructive dialogue that results in a shared decision by the spouses, but alternatively it may be based on conflict. Rather than the discussion itself, it is the man’s viewpoint during the discussion that appears to lead to the decision to start using contraception, as Armelle Andro and Véronique Hertrich have observed (2001). Therefore, the fact that the spouses have talked about how many children they want does not appear to be a reliable indicator of conjugal agreement on fertility, or of more egalitarian gender relations.

74Despite the diversity of contraceptive histories and modes of conjugal organization, we still identify a pattern of both spouses being involved in reproductive and contraceptive choices and practices, even if this occurs to varying degrees and in a context of shifting balances of power. According to three-quarters of the women, decisions are taken by both spouses, and even if they disagree, each spouse has a role to play in contraceptive choices.

75In a society that remains structured by generational hierarchy, where the extended family continues to exert strong pressure to promote the norm of having many children, the question of reproduction reveals the emergence of the couple as a decision-making unit. Indeed, in many situations, the couple’s desired family size is decided with little heed to the aspirations of the extended family. Among the most educated couples, the participation of both spouses in decision-making about contraception seems to indicate more egalitarian gender relations within the couple, and a profound transformation of gender relations in the Palestinian Territories. This trend in conjugal relations may well be one of the drivers of the current transformation in Palestinian society.