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.
1 – Analysis of the Palestinian Family Health Survey
8The Palestinian Family Health Survey (PFHS) was conducted in 2006 by the Palestinian Central Bureau of Statistics (PCBS) and the Pan Arab Project for Family Health (PAPFAM). It is based on a multistage stratified sample; 13,238 households answered the questionnaire (response rate: 88%), of which 8,781 were located in the West Bank and 4,457 in the Gaza Strip (PCBS, 2006). The survey module on sexual and reproductive health was only administered to ever-married women  of reproductive age (aged 15-54) identified within those households (N = 5,542). These women were asked about their attitudes and practices with regard to contraception as well as those of their husbands.
9From the information gathered in the survey, we defined indicators of contraceptive practice and of conjugal organization of fertility control.
10To evaluate contraceptive use, we measured the percentage of women who reported using contraception at the time of the survey  among married women at risk of pregnancy (married women who were not pregnant or menopausal at the time of the survey), who represented 80.9% of the female respondents (N = 4,486). 
11We preferred to measure contraceptive use “at the time of the survey” rather than “at any time in their lives”, which would only have provided a rough indication of contraceptive prevalence (R’Kha et al., 2006). The type of method was specified, distinguishing between medical contraceptive methods (a medical procedure or a hormonal treatment requiring the intervention of a healthcare practitioner: pill, intra-uterine device, contraceptive injection, implant, female sterilization or vasectomy) or non-medical contraceptive methods (which do not require medical intervention: male condom, female condom, periodic abstinence, withdrawal).
Indicators of conjugal relations with respect to fertility control
12We defined three indicators on the basis of the questions administered exclusively to women in the PFHS survey:
Variables used in the analysis
16Variations in the above indicators were analysed with respect to a series of variables:
- The socio-demographic variables that characterize the women surveyed (age, educational level, employment status), their husbands (age, educational level, employment status) and the conjugal relationship (length of the marriage, monogamous or polygamous union,  employment status of the couple (with the following modalities: “only the husband works; both spouses work; only the wife works; neither spouse works”).
- The variables constituting the fertility profile of the women surveyed: desired number of children, number of live births, number of daughters and number of sons.
- Contextual variables that characterize socioeconomic status,  place of residence (urban, rural and refugee camp) and region of residence (West Bank, East Jerusalem or Gaza Strip). In the Palestinian setting, the distinction between the three regions is important because of the separation policy implemented by Israel (Parizot, 2009), through a series of physical as well as administrative and bureaucratic barriers (Latte Abdallah and Parizot, 2011). The separation wall erected in 2002 reinforces this geographical fragmentation of the Palestinian Territories. Palestinians do not have the same freedom of movement or the same access to the labour market, and are subject to different laws, depending on whether they live in the West Bank, East Jerusalem or Gaza (Mitchell, 2010; Taraki, 2006). Restrictions on mobility are most severe in the Gaza Strip, followed by the West Bank, then East Jerusalem.
17After measuring the indicators of contraceptive prevalence and the conjugal indicators relative to fertility control, we analysed the differences in contraceptive practice by these socio-demographic, contextual, fertility and gender-relations variables, and by the conjugal relation indicators with respect to fertility. We examined separately the relations between each characteristic of the female respondents and the use of a contraceptive method (bivariate analysis); then we studied the joint impact of the different variables using a multivariate logistic regression model. In the model, we used only variables that were significant at 10% and non-collinear in the bivariate analysis. We also measured and plotted the percentage of women using contraception by number of previous sons and daughters born, and by the woman’s educational level.
18The probability that birth control decisions are made by the husband only or by the wife only was modelled using a polytomous multivariate logistic regression, and the variables were introduced according to the same principle (in this model, the reference response was “couple decides together”).
19Lastly, we used a logistic regression, again introducing the variables according to the same principle, to model the probability of using a non-medical contraceptive method rather than a medical method.
2 – In-depth interviews of married Palestinians
20We conducted  in-depth interviews in East Jerusalem and the West Bank  with 22 women and 20 men chosen according to various socio-demographic criteria in terms of age, educational level, number of sons, and place of residence (see Appendix Table A.1). Snowballing was used to recruit respondents from several initial sources: Palestinian family planning services, healthcare practitioners, and the interviewer’s family and friends.
21The semi-structured interview guide first invited respondents to talk about the environment in which they were socialized before their marriage. They were then asked to describe the division of roles within the couple, and to recount their reproductive and contraceptive history. None of the respondents were married to each other; all were asked about the choices and practices of their respective spouses.
22Informed oral consent was obtained from each respondent. The interviews were recorded, transcribed and anonymized by assigning fictitious names to the respondents. The interviews were conducted in English for those respondents who spoke English fluently; for the others, they were interpreted simultaneously into Arabic. 
23Thematic and content analyses were performed on the interviews, to investigate gender relations within couples, and their links to men’s and women’s attitudes to contraception and to their contraceptive histories.
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,  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).
Contraceptive use and indicators of conjugal relations with respect to fertility control (N = 4,486)(a),(b),(c)
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.
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)
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,  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).  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.
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.
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:
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”:
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.
3 – Family planning is a conjugal issue
37Three out of four women reported that birth control is decided by the couple (Table 1). The couple thus appears to be a locus of discussion and decision-making about contraception: six out of ten couples have already discussed the number of children they want. Contraception is used more often by couples who have discussed the desired number of children (56% versus 52%, OR = 1.06, Table 2) and by couples where the decision to use contraception is taken jointly. Contraception is used less frequently when only the husband decides (OR = 0.67) or only the wife decides (OR = 0.75) than when both spouses decide.
38This suggests that contraception is a conjugal issue, in terms of decision-making, fertility goals and communication. But it can also be a source of disagreement; in half of cases, the husband and wife disagree on the desired number of children (Table 1). When there is disagreement, the husband’s wish carries more weight: if the husband wants fewer children than his wife, 64% of women report using contraception, compared with 56% when the husband and wife want the same number of children (OR = 1.63, Table 2).
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.
1 – Typology of couples’ gender relations
40Based on the analysis of the 42 interviews, we identified three profiles of couples in terms of the gender relations between the spouses:
- Traditional couples (Profile 1,17 individuals) : relations between husband and wife are based on the traditional mode of male domination. The man is seen as the head of the family and the primary decision-maker. He plays the role of breadwinner and alone makes decisions about all family matters. The wife takes care of the household and children; she has extremely limited autonomy; some of these women report episodes of domestic violence. The individuals in this type of couple and their spouses have a low educational level: the vast majority have only primary or lower-secondary education and all live in villages or refugee camps.
- Egalitarian couples (Profile 2,15 individuals) : relations between husband and wife are based on a more egalitarian mode, where women have more autonomy and a rewarding activity outside the home, made possible by education and employment. The husbands are involved in household activities as well as childcare and childrearing. This profile includes all of the women who have tertiary education (except one with secondary education) and their husbands. Almost all live in a city, with three living in a village.
- Intermediate couples (Profile 3,10 individuals) : the roles of the spouses follow a traditional pattern of gendered division of labour, with the wife taking care of the household and children, and the husband providing the household income. However, unlike Profile 1, decisions about family matters are taken jointly. When problems arise, the spouses may look for a solution together. These individuals have upper-secondary or tertiary education. The majority live in a village and the remainder in a city.
41Communication between spouses and decision-making on fertility and birth control are expressed very differently in the three profiles, reflecting three distinct modes of conjugal organization in contraceptive decision-making.
2 – Birth control in traditional couples (Profile 1): the pressure of reproductive norms
42In the first profile, fertility choices and contraceptive use are under the husband’s control. There is communication but it is often conflict-based because the husband wants to impose his fertility goals against the wife’s wishes. Disagreements arise when the husband wants more children than his wife and/or refuses to accept spacing of births. The husband may forbid his wife from using contraception until the desired number of children – particularly the desired number of sons – has been reached, sometimes to the detriment of his wife’s health.
43One way for the husband to put pressure on his wife is to threaten her with repudiation or divorce. That was the experience of Oum [mother of] Shadi, whose husband refused to let her have an IUD implanted after three consecutive pregnancies and threatened to repudiate her if she did not give birth again soon.
That was our first argument with my husband about children. He was very angry when I told him about the lawlab (IUD). I expected my sisters-in-law to be supportive or at least understanding. I already had three children, we were all living under the same roof, it was very cramped, and we had no money. But in fact his whole family took sides against me, and all of them said we had to have more children (…). They made it clear that if I used an IUD, I would regret it, because I might even have to leave the house and above all lose my three children.
45Polygamy is another possible threat. This is reported by Oum Ramsy (58, six sons and four daughters), who stopped using contraception when her husband started looking for a second wife in order to have more children.
46The husband’s consent is required for female sterilization, which puts him in a position of power. The wife may have trouble obtaining it, and this can be a source of conflict, as it was for Oum Ali, whose husband subjected to her to a form of blackmail and psychological abuse, although he finally agreed.
To have the operation, I needed my husband’s signed consent. But he refused point blank. We already had seven children. I didn’t want any more, and I was not well. The doctor said I had to have it done because I was in danger of serious problems. It was very hard to convince my husband. He kept refusing because he wanted more children (…) He eventually agreed, but now he tells me every day that he wants twin boys and that if I can’t give them to him, he will take another wife. What can I do?
48In this profile, there is strong social pressure to have many children, especially sons. Until the woman has fulfilled the reproductive contract described above, contraception is the man’s decision. The quantitative analysis of the factors in contraceptive decision-making (Appendix Table A.5) confirms these observations: the probability of the wife alone deciding about contraception is higher among women at the end of their reproductive lives, i.e. among women who do not want any more children, who have sons, and who have been married for a long time.
3 – Egalitarian couples (Profile 2): co-responsibility and joint decision-making
49In the second profile, fertility goals appear to be determined by both partners together. Contraceptive choices are the result of joint decision-making. The men emphasize the importance of the emotional and conjugal relationship, beyond the desire for children, and are also very involved as fathers at every stage in the children’s lives. They prefer to have small families:
The contraceptive use of couples in this category reflects the preferences of each spouse. They addresses the issue in a constructive manner, in the sense that either spouse can initiate discussion and express his/her choices. Men and women see the value of communication for a good relationship. When the spouses agree on their reproductive goals, contraception is more likely to be a joint decision (Appendix Table A.5).I am very happy with my daughters. I spend a lot of time with them, I take them out a lot; we do lots of things together. But I don’t think we need any more children, because it’s important to have time just with my wife and not spend all our time taking care of the girls. For her too. She needs time for herself (…) They say that women and men should always be like two fingers together.
4 – Intermediate couples (Profile 3): the wife is responsible for contraception and the husband supports her
50In this profile, responsibility for contraception is strongly related to the gender division of roles. The woman, in charge of the household, is considered to have primary responsibility for reproduction and therefore for birth control. Unless they encounter specific problems with their contraceptive method, they rarely consult their husbands about contraception, managing their fertility themselves, in accordance with the reproductive role assigned to them: “The pill worked well for me; my doctor advised me to take it and I don’t see why my husband needs to be involved,” explains Rula (woman, 38, five sons and two daughters, East Jerusalem, 2011).
51Management of fertility may be shared with the husband if these women experience problems with their contraceptive method, particularly when medical contraception fails. Communication about birth control within the couple is constructive, aimed at reducing the risk of contraceptive failure. The husband may become actively involved in contraceptive choices, in a spirit of mutual support and shared responsibility.
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):
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:
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:
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): 
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.
Use of a non-medical method of contraception* by socio-demographic characteristics of the women and their husbands (bivariate and multivariate analysis, logistic regression) *
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”  (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  (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.
Socio-demographic characteristics of qualitative survey respondents (N = 42)*
Socio-demographic characteristics of qualitative survey respondents (N = 42)** The Tawjihi is the certificate of general secondary education.
Socio-demographic characteristics of female respondents to the PCBS/PAPFAM survey, 2006 (N = 4,486)
Socio-demographic characteristics of female respondents to the PCBS/PAPFAM survey, 2006 (N = 4,486)Note: The missing values for each variable were excluded from the analysis and are not shown in the table.
Percentage of women who report using contraception by number of liveborn children (N = 4,266)
Percentage of women who report using contraception by number of liveborn children (N = 4,266)
Percentage of women who report using contraception by number of liveborn children and educational level (N = 4,266)
Percentage of women who report using contraception by number of liveborn children and educational level (N = 4,266)
Organization of decision-making about contraception in the couple by socio-demographic characteristics of women and their husbands (bivariate and multivariate analysis, polytomous logistic regression, N = 4,486)
Organization of decision-making about contraception in the couple by socio-demographic characteristics of women and their husbands (bivariate and multivariate analysis, polytomous logistic regression, N = 4,486)Interpretation: Among women with basic education, the odds ratio between the probability that decisions about contraception are taken by the wife alone and the probability that they are taken by the couple jointly is 1.44 [0.85-2.44]; the odds ratio between the probability that decisions about contraception are taken by the husband alone and the probability that they are taken by the couple jointly is 1.59 [1.04-2.43].
Note: The model also factors in the woman’s age, the man’s age, the man’s educational level, the couple’s employment status, the number of daughters, and socioeconomic status. Only significant variables in the multivariate analysis are shown in the table.
Université Paris Descartes (PhD contract), Centre population et développement (CEPED, UMR INED-IRD-Université Paris Descartes), Paris.
Institut de recherche pour le développement (IRD), CEPED, Paris. Correspondence: Annabel Desgrées du Loû, CEPED, 19 rue Jacob, 75006 Paris, email: firstname.lastname@example.org
In Palestinian society, there is strong social stigma attached to pre-marital sexuality, so women who had never been married could not be asked about their sexual and reproductive practices.
The question was worded as follows: “Do you or your husband currently use any family planning method in order to avoid pregnancy?”
In its reports, the PCBS uses a different indicator to measure contraceptive prevalence, namely the percentage of women who use a contraceptive method among total women of reproductive age, without excluding divorced, single, widowed, pregnant or menopausal women.
“Do you think your husband desires to have the same number of children as you, a greater number or a smaller number?”
“Usually, who has the last say in using or not using family planning: you or your husband?”
“Have you ever talked with your husband about the number of children that you desire to have in your life?”
“Is your husband currently married to another woman?”
One of the methods most frequently used in Palestinian surveys to measure socioeconomic status is household ownership of durable goods. This information is used to define three categories: poor, middle-class, and affluent.
All of the interviews were conducted by the lead author of this article between January 2010 and December 2011.
It was not possible to conduct any interviews in the Gaza Strip, because only diplomats and humanitarian workers with a permit issued by Israel may enter the area.
The interpreter was a Palestinian woman from northern Israel doubly qualified as a social worker and as an English/Arabic translator.
Men and women with a “basic education” can read and write but did not complete primary school.
The figure ranges from 4.10 for women with basic education to 2.29 or women with tertiary education.
Data in Figures 1 and 2 are presented in Appendix Table A.3 and A.4.
The women who reported using condoms described them as a “natural” method because they are a purely mechanical barrier, which does not affect the woman’s body and has no side effects.
Courbage defines the concept of political fertility as a situation in which “the factors that usually promote a decline in fertility, particularly urbanization, industrialization and education, cease to have that effect” and links it the fact that “the welfare of the family and the children becomes secondary to the higher interest of the nation” (Courbage, 2011, p. 148).
Except vasectomy, which is rarely used in the Palestinian Territories.