Journal of Women's Health Care
Open Access

Determinants of Fertility and Contraceptive Use among Palestinian Women in the Gaza Strip: Qualitative Study

Khitam Abu Hamad^{* *}Correspondence: Khitam Abu Hamad, School of Public Health, Al-Quds University, Palestine, Tel: 0097282644210, Email:

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Introduction

The term “total fertility rate” is used to describe the average number of children that would be born to a woman over her reproductive age (15 to 49 years). It is based on the assumptions that a woman will experience the exact current age-specific fertility rates and will survive through the end of childbearing age [1]. This rate ranges from more than 7 children per woman in developing countries to about one child per woman in Eastern European and highly developed Asian countries [1,2]. A high fertility rate is often characteristic of developing countries because families in such countries usually desire a large number of children as laborers and as caregivers for parents in old age [3].

The fertility rate in the Occupied Palestinian Territory is not analogous to that of developing countries undergoing economic transition, in which improvement in socio-economic conditions and a reduction in mortality rates typically lead to a decline in birth rates; this is not the case in the Occupied Palestinian Territory. The demography of the Gaza Strip is of particular interest to demographers and researchers. The current fertility rate of 4.5 births per woman- with a population growth rate of 3.3% per - is one of the highest in the world despite the improvement in education, reduction in mortality rates, including infant and under five child mortality rates; and the accessibility and affordability of family planning services [4,5].

With the current on-going occupation, blockade, and political rift, the increase in population in the Gaza Strip poses challenges for developing a sustained economy as Gaza Strip is already desperately poor and has one of the highest unemployment rates (53.7%) globally [4]. Thus, the current population growth may make it impossible for the Palestinian National Authority to supply social services, including health services and infrastructure, to this congested population, most of who live on the edge of poverty [4]. This study examined the main determinants of fertility and contraceptive use among Palestinian women in the Gaza Strip.

Method

Based on the purpose of the study, six focus groups were developed. Three focus groups were with contraceptive users and three additional focus groups were held with contraceptive non-users. All focus groups were held in a non-threating environment. Participants were recruited from the family planning clinics of primary health care centres across the Gaza Strip. In addition of including women aged 15-49 years who had at least one child less than 5 years old, to ensure a wide range of data and different views and homogeneity among participants, participants were purposively selected based on a selection criteria developed by the researcher. The selection criteria included wide range of age among participants, variability in terms of differences in the total number of pregnancies and live births, and from different socio-economic background. It was not possible to include single women or women who do not have children. The focus group data were analysed using qualitative techniques. A professional transcriptionist transcribed the audio files verbatim (Arabic language). The transcriptions and discussion notes were organized by the research questions. Framework analysis as articulated by Ritchie and Spencer (1994) was used to analyse the focus group data. Participants were informed that participation in the focus groups discussion was completely voluntary and that they had the right to refuse to answer specific questions and to withdraw at any time during the discussion [6]. Participants were also told that participation in the study would not affect or jeopardize their treatment and services they will receive from the clinic and from their health providers. All respondents were promised confidentiality and signed consent forms to agree to participate in a focus group and to the recording the group discussions.

Results

Fertility intentions and household fertility decisions

Decisions about the number of desired children, fertility intentions, and contraceptive use were influenced by personal attitudes, as well as cultural, social, and religious factors. Overall, women in the focus groups and their families preferred a large number of children and viewed children as an asset and source of social security. The women in the focus groups favoured having many children. Most participants in the focus groups considered from three four to five children as the “ideal number” for a married woman who lives in the Gaza Strip. The majority stated that families can easily raise this number of children, offering them good care, good quality education, enough parental attention, and good healthcare. In addition, participants believed that this number maintains the general well-being of women, in particular their health status.

In response to the question of whether some women could have less than this number of children, four or five children, the majority of participants expressed the opinion that some women may have less than four children. According to those participants, employment, education, and poverty were the most important factors leading to having less than four children. Interestingly, the vast majority of participants stated employed women have more control over their fertility than women who are not employed.

With regard to household fertility decisions, the majority of the participants stated that household fertility decisions are shared between husband and wife. Most of the remaining participants stated that the household fertility decisions were made solely by the husband’s and a few participants, four, reported that they are made solely by wife. Among participants who reported that women had control over their fertility decisions, one put it this way, “Well, it depends on a woman’s personality and attitude. In my case, I am the person who decides how many children I want. I have the ability to convince my husband of what I want. I think most women can also do that” (Contraceptive user). This is an example of a woman making a decision by herself and convincing her husband to agree and bless her decision regarding the number of desired children and the use of contraceptives. It also shows how a partner can influence the other partner’s decision, thereby making it a shared decision.

Cultural influence on fertility intentions and contraceptives use

As in most conservative societies, in the Gaza Strip, a couple’s identity is defined by its childbearing ability. The woman’s ability to reproduce, particularly sons, affects her social standing, recognition, and marital stability. Participants in the focus group discussion strongly linked the cultural value attached to having children with fertility intentions and contraceptive use.

Palestinian culture requires families to have many children, so participants considered that having many children, particularly sons, heightens a family’s prestige and is a source of support mainly to parents, but this can extend to include the extended families. The majority of participants described having a large number of children by using the Arabic word E’zwa, which can be translated as children are a source of support, strength, and pride to their families.

Concerning the impact of culture on contraceptive use, the participants’ stated that the Palestinian culture in the Gaza Strip does accept the use of contraceptive, though this acceptance is conditional on three points. First, contraceptive methods may be used to space pregnancies, but not to permanently prevent pregnancy. Second, contraceptive use is supported only after having enough children. One participant put it this way, “In our culture, people do accept the use of contraceptives, but they advise a woman to have three to four children before getting old, then she can use family planning methods”. Third, a woman should have at least one son before using contraceptives. Like most Arab countries, Palestine is a patriarchal society in which men are the main decision-makers and hold positions of power and prestige. It was not surprising that all participants stated that son preference is one of the main motivating factors for having many children within a short interval.

Most participants perceived sons as a source of social recognition and, most importantly, a way to have martial stability. Other motivations and desires behind son preference are to promote the continuity of a family name, emotional support, and financial security for old age. Participants reported that women who have only girls do not use family planning methods until they have a son; after having a son, they hope for more sons. This view was expressed consistently by women in all focus groups who described women who had six girls before having the first son, then had another two or three girls with the hope of having another son. A participant stated, “My neighbour delivers only girls, she kept having children until she had a boy, but after having six girls” (Contraceptive user).

Women’s attitudes and knowledge of family planning methods and their use

The Palestinian culture does conditionally accept the use of family planning methods to space pregnancies, according to participants.

In response to the question, “What do you think about the topic that has brought us here today—the use of family planning methods?”, most participants reported feeling that family planning is “a positive” thing and it means spacing between children. It is worth mentioning that there was consensus among participants about the positive meaning of the family planning term to a degree that some participants mentioned that it even means a reproductive health. The majority of subjects indicated that every woman should use family planning methods to avoid having too many children in short period of time. This was a consistent view of both contraceptive users and non-users.

Most women who participated in the focus group discussions have good knowledge of different family planning methods; during the discussion almost all modern contraceptive methods, uses, and sideeffects were mentioned. Not surprisingly, the level of knowledge among contraceptive users appeared higher than among non-users.

The majority of participants stated that the intrauterine device and then pills were the most acceptable and the most commonly used methods, while hormonal injections followed by male condoms were the least acceptable and least used methods.

When contraceptive users were asked to mention the factors that made them decide to use contraceptives, the majority reported: (1) to space pregnancies with the intention to have more children in the future, (2) to stop having any children once they had the desired number, (3) economic hardship and the high cost of rearing children, (4) the health benefits of family planning for both women and children, and (5) to have time to meet needs other than child bearing. Participants in the contraceptive non-user groups gave the same answers, but with greater emphasis on spacing between pregnancies and the health benefits of family planning for women and children.

The participants believed that three main factors enabled women to use contraceptives when they wanted. The first factor was education, in particular college education among women. Participants stated that less educated women tend to have more children than educated women. The second factor was the fertility decision, if it was a shared decision between husband and wife. The third factor was women’s “awareness” of the risks associated with short intervals between pregnancies such as anaemia and hypertension. Participants from the focus groups reported that women who had more knowledge of these risks were more likely to use family planning methods and less likely to have more than five children.

The main reasons for not using family planning methods among contraceptive non-users were: (1) wanting more children, (2) not having approval for use from the husband, (3) unemployment among women, (4) believing that contraception could cause serious health problems, and (5) believing they will experience side effects. About half of the participants in the two non-user groups stated that they do not want children, but mentioned specifically and clearly that they would rather not use contraceptive and leave it to fate. Participants who had this view kept putting it this way: “I know my body; pregnancy is not going to happen; I do not know how I got this child; and I prefer to leave it to Allah [God]”.

Concerning side-effects of contraceptive methods, a contraceptive non-user stated, “I am afraid of the horrible side-effects of the contraceptive methods, I think I am not going to use any in the future and I will not advise other women to use contraceptive methods.” Similar comments were mentioned by three other contraceptive non-user participants.

Unemployment among women was consistently mentioned as a reason for not using contraceptive methods in the focus groups. A woman from one of the contraceptive non-users groups stated that she decided to stop using contraceptives and have more children because she could not find work. She put it this way, “Well, I was working on a temporary job as a teacher, and my contract was not renewed. I ended up by having nothing to do with plenty of spare time. So I decided to have another child, I became pregnant because I was feeling bored”.

Impact of religion, teachings of Islam, on contraceptives use

Most participants stated that religion, teachings of Islam, had no influence on their decision to use family planning methods. In response to the questions on barriers and reasons for not using contraceptives, none of the study participants, either contraceptive users or non-users, stated that religion, teachings of Islam, is a reason for not using contraceptives.

Interestingly, most participants in the focus groups stated that spacing between pregnancies through the use of contraceptives is permissible according to the teachings of Islam; however, from their point of view, Islamic teachings prohibit "permanently" ending a man's or a woman's ability to produce children. Those participants cited two verses from the Holy Qur'an to support their opinions: “Mothers shall suckle their children for two whole years; (that is) for those who wish to complete the suckling” and “His bearing and weaning is thirty months”. Interestingly, a participant from one of the contraceptive user groups interpreted the above verses to the other participants, saying “This is a clear message to space between pregnancies, in which if a woman were to nurse her baby for two years, she would need another year for pregnancy, which means at least three years spacing between two pregnancies”.

A dissonant view on the impact of religion on the use of contraceptives was stated paradoxically by few contraceptive users. From their point of view, Islamic teachings totally prohibit the use of family planning and they see practicing family planning as infanticide or going against the teachings of Islam. They cited from the Holy Qur'an the verse “And kill not your children for fear of poverty. We shall provide for them as well as for you. Surely, the killing of them is a great sin”. This opinion created a debate within that group and one of the women who mentioned this point concluded by stating, “Well, look who is supporting the family planning programs in the Muslim countries. Those are the countries that do not encourage the number of Muslims to increase”.

Most respondents also stated that teachings of Islam had no influence on their decision on the number of children desired. However, the majority of participants believed that having many children is encouraged in Islam and the Prophet Muhammad recommended Muslims do that. Contraceptive users and non-users agreed on this point. Participants cited many sayings of Prophet Muhammad “Hadith” to support their arguments. Examples of those citations are: “Get married and multiply” and “Marry and have children because I will vie the nations in number by you on the Day of Resurrection”. This point stimulated a hot discussion among participants about the definition of many children; most of them agreed again on many being four to five children.

Impact of the on-going Israel-Palestinian conflict on fertility and contraceptives use

Most participants in the focus groups shared the same opinion that the on-going Israeli-Palestinian conflict did not affect their decisions about the number of children they want. However, their responses were totally different when the following two questions were asked:

• What have you observed about how the conflict affects the decisions of other families in the Gaza Strip?

• Do you think the current Israeli-Palestinian conflict increases or decreases the number of children a family would like to have? Could you please explain why?

The majority of women stated that the conflict did influence the decisions of other families about the number of children desired by either increasing or decreasing the number. Those participants who stated that the conflict was likely to increase the desired number of children believed that it has taken an enormous toll on Palestinian people, with thousands killed, and therefore, that Palestinian families should have “a reservoir” of children to “compensate” for the number of “Saheed”, meaning martyrs. [In Arabic the word Shaheed, or “martyr,” is somebody who sacrifices his life for Allah's (God's) cause, his country, or his philosophy. It is also used to describe people who risk their lives to uphold truth and justice.

A participant in the contraceptive user groups said: Over the past 10 years, Gaza been subjected to three wars, we lost thousands of martyrs. Death is common and families who lost members are more likely to have more children. Another participant stated “No doubt that current conflict encourages families to have more children. When we lose someone, another one has to come. Finally, a non-contraceptive user stated “Yes, it encouraged people to have many children, for instance, if my son dies I will find another one”, said another participant as she held her son.

In contrast to these opinions, about quarter of participants stated that the on-going conflict could decrease the number of children desired and increase the uptake rate of contraceptives. They felt that the frequent wars on the Gaza Strip caused many families to be satisfied with their current number of children for two reasons. First, the conflict had devastating effects on children because they can be easily killed and many families do not want to bring children into the world to suffer and perhaps die without being able to offer them a good life. A contraceptive user, noting how quickly children may be killed in a conflict area, said, “Why have children [when] we know that our children will die like chickens?”. Second, during the last war, most Palestinian families fled from their homes seeking safer places. According to participants, families with a large number of children struggled more to evacuate than families who had fewer children. A current contraceptive user said, “Well, families, like my family, who have six children or more, during the wartime, everybody was helping us to evacuate our children. After the war, myself and many women that I know ran to the family planning clinics asking for IUDs”.

Impact of the deteriorated economy on contraceptive use

Women expressed two contradictory opinions about the impact of the devastated economy on both the number of wanted pregnancies and the use of contraceptives. The majority viewed the current deteriorated economy as encouraging the use of contraceptives because families cannot afford the cost of rearing large number of children. One participant put it this way: “Due to the current political situation and blockade, the economy has deteriorated in a miserable way. We live in poor conditions, we have no jobs, and so fewer children is better for us” (Contraceptive user).

The other view that was expressed by few participants is that the deteriorated economy encouraged some families to have more children to increase their share of the aid such as food stamps and coupons. The vast majority of Gazan families are unable to meet their basic needs, and most families depend on aid from UNRWA and other international and local organizations. This aid is distributed according to the family size: larger families get more.

Impact of lack of social security on fertility

Participants noted that their children will be able to look after them when they become old or if they get sick. They discussed the impact of the lack of social security, such as retirement policies and social welfare services to elderly people, on the number of wanted children. The majority of subjects stated that lack of such policies encourages families to have many children because children give their parents a better chance of security in their old age. One woman noted: “Who is going to take care of us when we become old? We need children to support us when we become old; the government does not offer anything for elderly people”.

In response to the hypothetical probing question, “If such policies are in-place, would that reduce the number of wanted children?” the vast majority of participants indicated that such policies would have an impact on them and they would not have the same number of children if those policies were in place. However, they believed the impact would not be large. One participant said, “Although the culture supports having a large number of children, this number will be reduced. For instance, instead of having six children, a woman could have four children”. Another participant added, “Those policies would encourage young couples in particular; they will use contraceptives earlier and will have fewer children”. Although women stated that the impact will not be large, reducing the number of wanted children from six to four would be a one-third reduction.

Discussion

The findings of the study showed that four to five children is the ideal number of children for a married woman who lives in the Gaza Strip, indicating that Palestinian society/culture is dominated by strong pronatalist practices that favour high fertility. The findings of this study showed that Palestinian culture accepts the use of contraception and that the utilization of family planning services is both accessible and acceptable to most women in the Gaza Strip. However, the study identified son preference as an important cultural barrier that has an effect on fertility. The study findings on son preference echoed results of other studies, particularly in developing countries, that found a negative effect of sex preference on contraceptive use regardless of other socio-economic variables and demographic characteristics [7-9].

Respondents in the focus groups stated that women in the Gaza Strip who have only daughters are less likely to use contraceptives, preferring to continue having children until giving birth to at least a son. Women’s two main motives behind son preference are to be recognized by their families and community and, most importantly, to have marital stability. Other general motivations and desires behind son preference are to maintain the continuity of the family name and emotional and financial support during old age. Although the study did not quantify the impact of son preference on fertility and contraceptives use, fertility rates could be reduced if son preference were reduced at earlier stages in family building. Strategies to decrease gender inequality and enable women to be economically and socially independent could help in reducing the preference for sons. Given the high level of education among Palestinian women, strategies that aim to increase women’s participation in the labor force might reduce the magnitude of son preference; however, this needs long-time period. Future studies are needed to quantify the impact of son preference on contraceptive use and fertility preferences among Palestinians. Furthermore, more qualitative research is needed to understand the socio-cultural complexities and nuances related to son preference.

Religion–“the Islamic doctrine”–does not have a direct effect on fertility decisions and contraception use

Scholars have frequently raised the question of where religions stand on contraceptive use and intensively studied it in different countries [7,9-11].

With regard to the Islamic countries or countries that have a majority of Muslims, Islam is one of the most frequently cited barriers to widespread adoption of contraceptive use. But Bernhart and Uddin (1990) stated that the view of Islam as a barrier to contraceptive use seems to be overstated [12]. Their view is supported by evidence from some Islamic countries that achieved remarkable success in reducing fertility rates such as Iran, Tunisia, and Egypt [13,14]. This study explored only one dimension of religion, which is whether doctrinal and philosophical teachings of religion have an impact on fertility decisions and contraceptive use among women in the Gaza Strip. The findings of the study indicated that doctrinal and philosophical teachings of respondents’ religion, Islam, are not a barrier to contraceptive use. It is interesting to note that none of the study participants, either contraceptive users or non-users, stated that the teachings of their religion are a reason for not using contraceptives. This finding is consistent with another study, in which the researcher participated, that found that religion is not a barrier to contraceptive use among refugee women in one of the Gaza Strip’s refugee camp [15]. Also, this finding is consistent with other studies, including ones conducted in, Egypt, Bangladesh, and Iran [7,9-11,13,14].

To the contrary, the finding is inconsistent with studies conducted in India, United Arab Emirates, Pakistan, and Kuwait [15-17]. The inconsistency with the findings of the above-mentioned studies might be attributed to differences in other socio-cultural factors, for example, the position of women in those communities and differences in the level of religiosity and exposure to different religious opinions.

As Islamic doctrine does not define or specify a certain number of children that a family should have, the quantification of “many children” was discussed in the focus groups, and according to participants, having four or five children constitutes having “many children” [Neither in Al-Quran nor in Hadith, narrations concerning the words and deeds of the Prophet Muhammad, is the number of children a woman should have specified].

Interestingly, having four or five children is the ideal number of children that respondents mentioned at the beginning the focus group discussions. In other word, although participants believe that Islam does encourage fertility and reproduction, this belief does not influence women’s desired/actual fertility as measured by the number of desired children. Other driving forces such as the Israel-Palestinian conflict, the lack of social security policies, and other socio-cultural factors are key determinants that influence and enhance women’s fertility decisions of having four or five children.

Other dimensions of religion that could have an indirect impact on determinants of fertility such as social and other cultural dimensions were not investigated in the study. As discussed later in this chapter, the current Israeli-Palestinian conflict might impact fertility behaviour in different ways, including the religious aspects of the conflict. It is also important to note that this study finding has some limitations including: the study did not investigate the relationship between level of religiosity among women and their fertility. Secondly, the study did not investigate the link between socio-economic levels, religiosity, and fertility behaviour; and finally, the study did not compare the fertility difference between Muslims and Christians women in the Gaza Strip.

Employed women have fewer children and are more likely to use contraceptive methods

As expected, participants of focus groups stated that lack of employment is a motivating factor for them and for other women to have more children. Also, respondents recommended increasing the number of available jobs for women as a way to motivate them to use contraceptives and have fewer children. The above findings on women’s employment are consistent with the economic theory of fertility that considers women’s education as a proxy for the value of women’s time. From an economic perspective, the value of women’s time comes from being active in a labor force. According to this perspective, women’s employment increases the opportunity cost of children; thus, women’s fertility decreases. Given the high level of education among women in the Gaza Strip and the low rate of women’s labor force participation (19.9%) [5], the fertility rate in the Gaza Strip suggests that educating women without integrating them into the job market has little effect on fertility. This scenario of the relationship between women’s employment and education is consistent with Syria’s experience in fertility reduction, in which the fertility rate declined not due to a high level of education among women, but due to an increase in the rate of women’s participation in the labor force [18].

Confirmation of a relationship between lack of social security and high fertility

The findings of study confirmed that securing old age support motivates Palestinian women/families to have many children and is thus, according to study participants, a barrier to early use of contraceptive methods. Specifically, the lack of social security policies and welfare services, including security payments to needy elderly people, is a driving force to have many children, particularly sons. Participants in the qualitative study considered children economic assets and asserted that parents deliberately have children to support them emotionally and financially and to care for them in their old age. This finding resonates with the intergenerational wealth flows theory that suggests that old age security and the relationship between the individual and the larger family are among the main determinants of fertility.

Although this study did not quantify the impact of the lack of these policies on fertility reduction and contraceptive use, participants in focus groups indicated that fertility reduction could be one-third of the current fertility rate if such policies were in place. Further studies are needed to determine the impact of the lack of social welfare systems on families’ decisions regarding the desired number of children and contraceptive use.

Confirmation of a relationship between women’s fertility intentions and the Israeli-Palestinian conflict

One cannot discuss the fertility of Palestinians without discussing the potential effect of the current Israel-Palestinian conflict on Palestinians’ fertility. Historically, demographic measures have been pivotal tools in the establishment and expansion of Israel. The demographic transformations of Palestine over the past century summarize the story of the conflict, in which demographics and population growth have always been intimately and crucially related the Israel-Palestinian conflict. Indeed, the heart of Zionist Movement was the de-Arabization and consequent Judaization of Palestine [19].

Leaders on both sides have brandished fertility rates as if they were guns at the ready. On the Israeli side, Israel’s Zionist leaders have historically viewed Arab fecundity as a threat to Israel’s existence [19]. Starting in early 1940s, David Ben-Gurion viewed the demographic issue as one of the most important issues to Israel and he occasionally asked Jewish people to fulfil what he called their “demographic duty” [20]. On the Palestinian side, the late Palestinian president Yasser Arafat coined the adage that the “Palestinian womb is the Palestinians greatest weapon”. Politicians as well as demographers use the term demographic war to describe the demographic competition between Palestinians and Israelis.

Two things stand out from exploring the impact of the Israeli-Palestinian conflict: the conflict’s direct impact on fertility and its indirect impact through the effect of the deteriorated economy on fertility. First, the direct impact of the conflict on fertility, findings from this study confirmed that the current Israeli-Palestinian conflict is a driving force for fertility, and thus an impetus to having many children. The current political situation makes the high fertility in the Gaza Strip desired due to two factors. First, women/families desire more children as insurance against expected deaths due to the on-going Israel-Palestinian conflict. Second, although women did not mention the term “demographic war” between Palestinians and Israel, most participants considered giving birth to children their duty and their contribution to liberating Palestine through compensating for martyrs and, thereby, maintaining the momentum of resistance against the Israeli occupation. The number of studies on fertility among refugees or displaced populations is sparse [21]. The findings of this study on the war’s impact on fertility are inconsistent with the literature on Lebanon, Iraq, and Iran. Research in those countries illustrated that wars have no impact on fertility [21,22].

In fact, this study’s findings echo the study conducted in the Galilee area by Rhoda Ann Kanaaneh (2002) [19]. In her 2002 study of the politics of the fertility of Palestinian women in the Galilee area, she found that Palestinian women consider giving birth to children as their contribution to resisting the Israeli colonialist agenda and as a form of resistance against Israeli efforts to limit the size of the Palestinian population. Specifically, Kanaaneh used the term “birthing a nation” to describe the women’s fertility.

Second, indirect impact of the conflict on fertility through the deteriorated economy, the other view on the impact of the Israeli-Palestinian conflict is that it would be unlikely that war would lower the fertility rate, but it might happen due to the devastating impact of the conflict on the economy. Israel openly declared that the economic sanctions are aimed at paralyzing Gaza’s economy as a way of exercising pressure on the Hamas regime. As anticipated, the study found that economic hardship and the high cost of rearing children were reasons women gave for contraceptive use, particularly after the last wars on the Gaza Strip, and for the increased desire to be satisfied with their current number of children. On the one hand, this finding is inconsistent with previous research studies and classical demographic theory that state that wealth and fertility are negatively correlated. On the other hand, it is consistent with previous research studies that found an association between economic stress and reduction of fertility. Johnson-Hanks (2006) used the term “a crisis in motherhood” to describe the negative relationship between deteriorated economic circumstances and fertility [23]. For instance, in Ethiopia, poverty was the root of fertility reduction [24]. This was also the case in Syria, where the deterioration in the economy forced women to delay marriage and enter the labor market, resulting in a rapid decline in fertility during 1970s [18,23,25]. A similar situation was found in Cameroon [23,25].

Conclusion

To conclude, this study did not find a single relationship between the on-going Israeli-Palestinian conflict and the fertility rate in the Gaze Strip. Thus, from my point of view, the TFR in the Gaza Strip may vary around 4.5 births per woman without significant decline as long as people feel insecure and face a wide range of uncertainties about their future and their children’s future.

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