FACULTY OF HEALTH AND MEDICAL SCIENCES UNIVERSITY OF COPENHAGEN

Master’s thesis – Public Health Science Liv Nanna Hansson, MSc student of Public Health

Beyond Numbers: Political Fertility in Palestine An ethnographic study of perceptions of fertility among refugee mothers, health providers, and policy planners

Danish title: Mere end blot tal: Politisk Fertilitet i Palæstina. Et etnografisk studie af forståelser af fertilitet blandt flygtningekvinder, sundhedspersonale og policy planlæggere Main academic advisor: Siri Tellier, Dept. of Public Health, University of Copenhagen Secondary supervisor: Lotte Buch Segal, Dept. of Anthropology, University of Copenhagen Submitted: 2 n d of April 2012 Characters: 239.867 (approx. 100 pages of 2400 characters)

Front-page photo: A young Palestinian boy dressed in military uniform holding a Palestinian flag, sitting on the shoulders of his father, at the celebration and live-transmission in Ramallah of President Mahmoud Abbas’ speech at the United Nations General Assembly in New York where he applied for Palestinian state-membership of UN. Ramallah, 23rd of September 2011. Photo by LNH

Resumé: Mere end blot tal - Politisk fertilitet i Palæstina. Et etnografisk studie af forståelser af fertilitet blandt flygtningekvinder, sundhedspersonale og policy planlæggere. Introduktion og formål. I Palæstina har antallet af børn per kvinde historisk ligget højt, og fertilitetsraterne har ikke fulgt den transition, vi kender fra klassisk demografi. Fertilitet spiller en politisk rolle i konflikten med Israel, og derfor tilskrives den høje fertilitet en politisk fertilitet. Ved at benytte en etnografisk tilgang muliggøres en udvidelse og udfordring af dette begreb med rødder i demografien. Dette speciale spørger derfor, hvad begrebet politisk fertilitet indebærer for flygtningekvinder fra Kalandia flygtningelejren på Vestbredden og for sundhedspersonale og policy-planlæggere, der arbejder med familieplanlægning på Vestbredden. Metode. Indsamlingen af empiri blev foretaget september-oktober 2011 i Ramallah og Kalandia flygtningelejren. Der er gennemført interviews med flygtningemødre i Kalandialejren og med repræsentanter for de organisationer, der har afgørende roller for reproduktive sundhedsydelser på Vestbredden. Herudover er der foretaget deltagerobservationer under ophold i FN’s sundhedsklinik i Kalandia. Det empiriske materiale indeholder semi-strukturerede interviews, uformelle samtaler, deltagerobservationer samt brochurer fra klinikken. Materialet er analyseret ved hjælp af teoretiske begreber om magt, biopolitik og diskurs. Fund og konklusioner. Studiet finder, at mødrene tilskriver konflikten en betydelig rolle for fertilitet. De frygter, at deres børn dræbes eller fængsles af israelsk militær. Ufrivillig barnløshed opleves som et afgørende problem blandt kvinderne, men ikke i samme udstrækning hos sundhedspersonale og policy-planlæggere. Policyplanlæggerne anser det ikke for politisk muligt at tale om fertilitet som omhandlende antal børn. Det konkluderes, at der er tydelige politiske aspekter i forståelser af fertilitet i Kalandia, både blandt mødre, i den kliniske hverdag og blandt policyplanlæggere. Denne politiske fertilitet har dog ikke et fast fortegn, men kan medføre både færre og flere børn. I stedet for at tale om familieplanlægning som omhandlende antal af børn, tales der i stedet om timingen af at få børn, fordi dette ikke opfattes som politisk betændt. Hermed bliver det muligt at udbyde og benytte familieplanlægning på Vestbredden.

I want to thank all who allowed the fieldwork to take place, allowed me into their homes, and took time to help me by sharing their experiences with me. I hope my efforts will turn out useful. The fieldwork for this study was supported by Danida Fellowship Center.

Liv Nanna Hansson April 2012

Contents 1

2

3

Introduction .................................................................................................................... 5 1.1

Problem statement ................................................................................................. 7

1.2

Outline ..................................................................................................................... 9

Context .......................................................................................................................... 10 2.1

Fertility in the Middle Eastern region and in Palestine .................................. 10

2.2

Family planning .................................................................................................... 15

2.3

The setting of the refugee population in the West Bank ............................... 16

2.4

The health care setting of Palestinian refugees in the West Bank ................ 17

Methodology ................................................................................................................. 19 3.1

Methodological point of departure ................................................................... 19

3.1.1 3.2

4

Ethnography ................................................................................................. 21

Methodology: operational dimension ............................................................... 22

3.2.1

Literature search .......................................................................................... 22

3.2.2

Ethnographic fieldwork .............................................................................. 23

3.2.3

Analytical strategy ........................................................................................ 34

Theoretical framework ................................................................................................ 37 4.1

Demographic framework for understanding fertility ..................................... 37

4.2

Power, biopolitics and discourse ....................................................................... 39

5

Empirical Evidence and Analysis............................................................................... 43

6

I) Having Children: Making the Decision................................................................. 44 6.1

The point of view of mothers ............................................................................ 44

6.1.1

The setting in which the mothers live ...................................................... 44

6.1.2

What mothers say: it is natural to have children ..................................... 45

6.1.3

Knowledge and utilisation of family planning methods ........................ 46

6.1.4

Infertility ....................................................................................................... 46

6.2

The point of view of policy planners and health providers ........................... 49

6.2.1

The setting of providing family planning services .................................. 49

6.2.2

Infertility was not on the policy agenda ................................................... 51

6.3

Triangulation: deciding fertility .......................................................................... 52

6.3.1

Political perspectives’ contribution to demographic knowledge .......... 53

6.3.2

Biopolitics ..................................................................................................... 58

Beyond Numbers: Political Fertility in Palestine 7

II) Being Palestinian: Palestinian Positioning ........................................................... 63 7.1

The point of view of mothers ............................................................................ 63

7.2

The point of view of policy planners and health providers ........................... 67

7.3

Triangulation: Positioning Palestinian fertility ................................................. 70

8

7.3.1

Discursive phrases ....................................................................................... 70

7.3.2

Development and modernisation .............................................................. 72

III) Having Children in Palestine: Beyond Numbers ............................................. 75 8.1

The point of view of mothers ............................................................................ 75

8.2

The point of view of policy planners and health providers ........................... 77

8.3

Triangulation: fertility is not (just) a number ................................................... 79

9

8.3.1

Mothers do calculus without numbers ..................................................... 79

8.3.2

From ‘numbers’ to ‘spacing’ ...................................................................... 82

Discussion ..................................................................................................................... 88 9.1

Discussion of methodological choices.............................................................. 88

9.2

Discussion of quality of research ....................................................................... 91

9.3

Ethical considerations ......................................................................................... 97

9.4

Public health relevancy: drawing perspectives ................................................. 99

10

Conclusion .............................................................................................................. 101

Appendix I: Collection of empirical data ........................................................................ 104 Appendix II: Participant Observation guide .................................................................. 105 Appendix III: Collection of Interview Guides ............................................................... 106 Appendix IV: Condensation of empirical material ........................................................ 114 Appendix V: Consent Form for UNRWA Kalandia Clinic ......................................... 116 References............................................................................................................................ 118

2

Introduction

Map of the West Bank and Kalandia camp

Source: United Nations Office for the Coordination of Humanitarian Affairs, occupied Palestinian territories, Humanitarian Atlas 2011 (ochaopt.org)

3

Beyond Numbers: Political Fertility in Palestine

Abbreviations ANC CEDAW DESA DTM ICPD ICPH IUD IVF MCH MENA MoH MoP NCD oPt PCBS PHC PNA TFR U5MR UN UNFPA UNLU UNRWA WHO

Antenatal Care Convention on the Elimination of All Forms of Discrimination against Women United Nations Department of Economic and Social Affairs Demographic Transition Model International Conference on Population and Development Institute for Community and Public Health Intrauterine Device In Vitro Fertilisation Mother-and-Child Health Middle East and North Africa Ministry of Health Ministry of Planning Non-communicable Disease occupied Palestinian territories Palestinian Central Bureau of Statistics Primary Health Care Palestinian National Authority Total Fertility Rate Under-five mortality rate United Nations United Nations Population Fund Unified National Leadership of the Uprising United Nations Relief and Works Agency for Palestine Refugees World Health Organization

Abbreviations use for indication of empirical material A-HXX LNH MoHXX MoPXX OBS UNFPAXX UNRWABX UNRWAXX

4

Indication of informant (mothers, see Table 1) and line number Liv Nanna Hansson – used to indicate my own translation/photo Interview with policy planner from MOH – line number in transcription Interview with policy planner from MOH – line number in transcription Observations (see field notes) Interview with policy planner from UNFPA – line number in transcription UNRWA Brochure no. 1-4 Interview with policy planner from UNRWA – line number in transcription

Introduction

1

Introduction “Our women’s wombs are our greatest weapon” Former Palestinian president Yasser Arafat1

Metaphors describing Palestinian fertility are abundant. Palestine is referred to as the motherland (Massad, 1995), Palestinian women as ‘giving birth to the nation’ (Kanaaneh, 2002) or the nation of Palestine as ‘a beast who devours her children’ (Sahar Khalifeh as quoted in Amiry, 2010:160). Yet the statements most central to Palestinian fertility are those of former Palestinian president Yasser Arafat. He has phrased Palestinians women’s wombs as the greatest weapon of Palestine, emphasising the political role of fertility and linking fertility to the Israeli-Palestinian conflict as a peaceful way to fight the occupation2 (Kanaaneh, 2002; Courbage, 2011a; Fargues, 2000). This is a thesis on perceptions of fertility3 in Palestine, more precisely in the United Nations Relief Works Agency for Palestine Refugees (UNRWA) refugee camp in Kalandia located in the outskirts of Ramallah in the West Bank in the occupied Palestinian territories (oPt). In the global discourse on reproduction two differing positions emerge. As a response to the concerns of population growth, a ‘population control’ agenda took form in the 1970s which focused on ways to limit population growth. The International Conference on Population and Development (ICPD) held in Cairo in 1994 marks an important move away from this old ‘population control’ view (Hardon et al., 2001:78), by emphasising the reproductive rights of the individual to their own body. The tension between these two opposing positions delineate what is at the core of how family planning is seen today – a method for a government to control population growth or a tool for the empowerment of women to make decisions about their own reproduction? States intervening in fertility is not new. Rather family planning services can be understood as the governing of the reproductive behaviour of a 1Arafat

is quoted to have stated this (or in similar phrasing) in several accounts (Fareed Zakaria, 2001). By the occupation, I am referring to the Israeli occupation of the West Bank, East Jerusalem and Gaza Strip. I use the term ‘occupation’ in accordance with the UN Resolution 242 of 1967. 3 Fertility is in this thesis understood as ‘having children’ and the focus is on choice and practice, and not on the ability to have children (termed fecundity). 2

5

Beyond Numbers: Political Fertility in Palestine population. At the same time family planning is a right of women stated in the Convention on the Elimination of All Forms of Discrimination against Women. There is a political dimension to a population having children, whilst having children is at the same time very intimate and private. Exactly how this dynamic is played out is the grounds for my study. From as early as the 1920s much effort has gone into making family planning accessible and available. At the ICPD it was agreed that family planning is a key element in reproductive health care which should be made accessible through the primary health care system (Hardon et al., 2001:71). However, family planning methods become a politically sensitive issue as authorities call for more children (Bosmans, Nasser, Khammash, Claeys, & Temmerman, 2008) and hence their provision and utilisation cannot be rolled out without an eye for the political context. Palestine is in a unique political situation of occupation and conflict4, making fertility in this context especially contested. After a recent significant decline, the total fertility rate (TFR)5 in Palestine is currently 4.1 children per woman (PCBS, 2011). This is higher than both that of neighbouring countries and what we would expect from classic explanatory socio-economic and health factors. In a setting with a high level of education of women and low child mortality, such as Palestine, a lower level of fertility would be expected according to classic demography, posing a demographic conundrum. With the metaphors presented above it is evident that fertility play a special role in relation to the conflict, and the concept of political fertility has been framed. Understood by scholars as the main explanation of the high fertility in Palestine, political fertility is a concept used to describe fertility in cases where the fertility rates do not follow patterns seen in other populations and where the political situation is thought to be the explanation. Demographer Youssef Courbage defines the concept political fertility as “when the normal factors which induce a drop in fertility, notably urbanization, industrialization, and the level of instruction, cease to operate” (Courbage, By conflict, I refer to the Israeli-Palestinian conflict. I will not provide a historical overview or presentation of the conflict as my analysis does not focus on historical events, but on the current lived situations and should be seen more as a glimpse into the lives of Palestinians. These are of course influenced by history, yet it is not the scope of this thesis to investigate this. Scholars from numerous disciplines are engaged in this and it is not my aim to provide another contribution to the massive literature on the conflict. 5 Total fertility rate (TFR) is defined as the mean number of children a hypothetical cohort of women would have at the end of their reproductive period if they were subject during their whole lives to the fertility rates of a given period, and if they were not subject to mortality. It is expressed in units of children per woman (Population Reference Bureau, 2011). 4

6

Introduction 2011b:148) and ascribes it to when the “well-being of family and of children becomes a secondary issue compared to the higher interests of the Nation” (Courbage, 2011b:148). Here we have a situation where knowledge from the classic demographic prognosis falls short and where the need for further explanations is pressing. The concept of political fertility is introduced, but what is the substance of this concept? What does it entail, and for whom is it relevant to speak of? It is a widely held view that the phenomenon should be particularly relevant amongst the Palestinian refugee population (Khawaja, 2003) which accounts for one third of the population of the West Bank (UNRWA, 2011b). This notion of ‘political fertility’ both fascinates and provokes me. The understanding of fertility as having a political dimension opens up for analysis the role of policy and technologies for governance within the field of fertility. On the other hand, the coining of such a term implies a danger of simplification and ascribing meaning to others’ actions. This dynamic yields a multitude of questions: what are the implications of coining fertility as a political entity? Who are linking fertility to the conflict? Is the political situation of importance for women in relation to motherhood in Palestine? Does political fertility, if such a factor exists lead to higher or lower fertility? 1.1

Problem statement

So, in view of the recent decline in, yet comparatively high levels of fertility rates and the special dynamics of the political interests at stake I wish to look at fertility in occupied Palestine. Arafat phrased fertility as political, but does this adequately explain the lived experiences of fertility today? Fertility and the decision to have children are at the very core of the private sphere of the family and of a woman. However it is at the same time a highly political sphere and health politics can play a major role in the perceptions of having children. Thus the decision to have children lies between public health policy and the private sphere, perhaps especially so in the context of Palestine due to the Israeli occupation. I wish to approach this from a bottom-up perspective to capture the delicateness of everyday life of mothers and families in addition to the political aspect of fertility. This leads me to the following problem statement: what is political fertility, and how does it play out in the Kalandia refugee camp among refugee mothers, the UNRWA health clinic and policy planners?

7

Beyond Numbers: Political Fertility in Palestine This thesis will try to grasp how decisions to have children in Palestine are constructed with a political understanding, with insights from multiple arenas: policy planners working with family planning, health providers, and refugee women who themselves are mothers. I wish to understand to what extent ‘political fertility’ is perceived to be an influence on the decision to have children. The concept of political fertility can be present at multiple levels: at the level of those implementing policies, health services and programs and on the ground on a personal level for Palestinian refugee women living in the West Bank. I wish to empirically shed light on the concept, and with reference to the refugee population in Kalandia camp in the West Bank I have conducted ethnographic fieldwork over the course of two months in the West Bank6. My findings are based on interviews with eight refugee mothers from Kalandia refugee camp and four high-level policy planners working with family planning policy as well as more than one week of participant observations conducted in the UNRWA health clinic in Kalandia refugee camp. The Palestinian case has been characterised as a “unique and idiosyncratic” (al-Malki, 2011:195) research challenge, and the majority of studies of the Palestinian people take the Israeli-Palestinian conflict as their object of study (al-Malki, 2011). With this study I wish to provide a platform giving voice to those ‘behind’ the rates of fertility, the mothers of Palestinian children in Kalandia, and to enrich demographic knowledge by approaching a public health field with an ethnographic methodology. The public health relevancy of this study of health politics, health practices and health perceptions is found in the contribution to the understanding of what is at stake for fertility policy and provision of family planning services, as well as what is shaping the perceptions of the mothers having children. Such understanding enables navigation in a health policy arena to ensure the development of greater health and wellbeing for Palestinians. In order to target family planning programs better understanding of what is at stake for the mothers, the recipients of these services, is necessary. And globally, with growing population numbers, insights into the interplay of politics and fertility will play an important role in securing rights for family planning in the future. I hope that this thesis can be read as a call for the public health domain to

The occupied Palestinian territories refer to the Gaza Strip, East Jerusalem and the West Bank. I focus on the West Bank, as access to Gaza Strip was not possible due to the Israeli siege on the Gaza Strip. 6

8

Introduction give weight to the political aspects concerning both daily life decisions and healthpolitical navigations. 1.2

Outline

After this introduction to the problem field, rationale and objective of this study, I present a review of the scientific literature of the field of fertility in Palestine to enable an understanding of the choice of methodology as well as the findings of this study. I then present my methodology in detail and hereafter the theoretical concepts of demography, power, biopolitics, and discourse that have been applied in the analytical process. There then follows the chapters of analysis (Chapters 5-8) in which I discuss the three research questions that have emerged from my empirical material; Having Children, Being Palestinian; Beyond Numbers. After the analytical chapters, I discuss the research process and the implications of these findings and draws perspectives to underline the importance of the study. I finish the thesis with presenting my findings and conclusions.

9

Beyond Numbers: Political Fertility in Palestine

2

Context

To contextualise the forthcoming analysis, I will here present concepts that are crucial to define in order to understand my approach as well as my results. Firstly, I present the current literature on fertility in Palestine based on an extensive literature search and draw up the current gaps in knowledge. The same literature review has informed my choice of problem statement and is the basis of the questions posed in the previous chapter. Secondly, I lay out the definition of, and right to, family planning, while finally I present the context of the Palestinian refugees. 2.1

Fertility in the Middle Eastern region and in Palestine

Fertility in the Middle East has undergone rapid transition within the last decades while in a global context the TFRs remain high. The population of the Middle East grew almost sixfold during the 20th century, despite vast emigration from the region (Winckler, 2009), and at the beginning of this century the Middle East and North Africa (MENA) region had the second highest fertility rate of all regional rates (World Bank, 2011). The fertility rates in Palestine are one of the highest in the Arab world (Rahim et al., 2009), with only Yemen and Iraq having higher TFRs among the countries of the Middle East (Population Reference Bureau, 2011). With the numbers from the United Nations Department of Economic and Social Affairs’ (DESA) population prospects (Figure 1), we can see that since the middle of last century the TFR of Palestine has been higher than the average of both Northern Africa and Western Asia7. All three rates have declined over the last 60 years, yet while the rates of Northern Africa have converged to those of Western Asia, this is not the case for Palestine. Other combined data confirms that it was not until the early 1990s that the fertility rate of Palestine started to decline, as TFR in Palestine was stable at approximately 7 births per woman from the 1960s until the early 1990s (Giacaman et al., 2009). Palestinian fertility is not only higher than neighbouring countries’, it also started a transition later.

7Northern

Africa is defined as Algeria, Egypt, Libyan Arab Jamahiriya, Morocco, Sudan, Tunisia, and Western Sahara. Western Asia is defined as Armenia, Azerbaijan, Bahrain, Cyprus, Georgia, Iraq, Israel, Jordan, Kuwait, Lebanon, Occupied Palestinian Territory, Oman, Qatar, Saudi Arabia, Syrian Arab Republic, Turkey, United Arab Emirates, and Yemen. The data from the oPt includes East Jerusalem. (DESA, 2011)

10

Context

Total Fertility Rate, children per woman

Total Fertility Rates of Northern Africa and Western Asia (incl. oPt) 9 8 7 6 5 4 3 2 1 0

Occupied Palestinian Territory (oPt) Northern Africa Western Asia Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World Population Prospects: The 2010 Revision, http://esa.un.org/unpd/wpp/in dex.htm. Accessed the 28th Februar 2012

Figure 1. Estimates of total fertility rates in the Occupied Palestinian Territory, Northern Africa and Western Asia from 1950-2020. Data from DESA’s World Population Prospects (DESA, 2011).

From the middle of the 1990s the decline in the fertility rate in Palestine has been significant, albeit the rates differ from those in the rest of the region. Within the last decade, the TFR of Palestine has declined by 29% according to the national Palestinian Central Bureau of Statistics (PCBS) (PCBS, 2011). Within these numbers for Palestine hides the different rates of the West Bank and Gaza Strip. Historically, these have been similar, but data shows that since the mid-80s the rates have been diverging (Figure 2). The TFR in the Gaza Strip remained at the level of 7 births per woman until the mid-90s8 when it dropped to 5.5-6 births over the following decade. The decline in the West Bank was more gradual and started a decade earlier, in the mid-80s (Giacaman et al., 2009). The most recent numbers from the Palestinian Central Bureau of Statistics show that the current total fertility rate of the West Bank is 3.8 births per women (PCBS, 2011). The decline in fertility has been most pronounced amongst the refugee population. It has been shown that the largest decline in fertility from the mid-80s to mid 90s in the West Bank has been recorded amongst refugees living in camps as compared to non-refugees and refugees living outside camps (Khawaja, 2003). 8

This is around the same time as the first Palestinian Intifada ended with the Oslo Accords in 1993.

11

Beyond Numbers: Political Fertility in Palestine

Figure 2. Total Fertility Rates of the West Bank and Gaza Strip (register and survey data) from 1968 to 2003. Data is aggregated by a Lancet series by Giacaman et al from studies of Khawaja, PCBS and other sources. (Giacaman et al., 2009).

Politically tense demography Demography is seen as an embedded part of the Israeli-Palestinian conflict (Courbage, 2011a), as a major part of the nation-building of both sides (Fargues, 2000), and not merely a resulting concept of the conflict for two parts (Khawaja, Assaf, & Jarallah, 2009; Bosmans et al., 2008). According to Courbage it was in part the population projections which estimated that Palestinians (including Israeli Arabs) would outnumber Israeli Jews by 2005/10 that led to a speed up of the 1993 peace negotiations (1995). In the West Bank, population growth has become a crucial instrument for both Jewish settlers and Palestinians in attempts to outnumber the other to gain control over land, thus making fertility and reproductive health a highly political arena (Bosmans et al., 2008). Palestinian authorities have encouraged women to have more children while donor organisations and public health advocates encourage family planning and fewer children (Bosmans et al., 2008). Hence, different interests influence the fertility rates and decision to have children in the oPt. But to what extend does the conflict matter compared to other factors which are commonly are used to understand levels of fertility? Determinants of fertility Within the demographic literature, the determinants of fertility have been identified to be either developmental factors (such as urbanisation, child survival and education) or proximate determinants (such as age of marriage, use of contraception and 12

Context fecundity9), while some proximate determinates are influenced by developmental factors (Gould, 2009). The determinants of fertility vary from setting and over time according to norms, cultural preferences and biological differences in the ability to reproduce (Gould, 2009). As stated, fertility in Palestine is higher than in neighbouring countries. Also, if one were to extrapolate from factors associated with fertility such as educational levels, urbanisation or child health, the current Palestinian fertility rate is much higher than would be expected (Courbage, 1995). A number of studies have looked into the factors commonly linked with fertility. In Palestinian populations, Khawaja finds an overall relationship between TFR and educational achievement of women, and this association is u-shaped for the Palestinians residing in the oPt, meaning that the lowest and highest educated have the highest fertility rates (Khawaja, 2003). Pedersen, Randall, and Khawaja suggest that the lack of a linear effect of education on fertility could be due to lack of employment possibilities for women in the West Bank (2001:118). Another study shows that the observed decline in fertility seems to be related to changes in marriage patterns in the West Bank and not to contraception use, as the latter has remained consistently high during the decades of fertility decline (Khawaja et al., 2009). Marriage patterns might partially explain the high fertility, but as with other studies, it fails to explain fully why fertility rates have been as high as they have been and remain to be. The urbanisation and low levels of female illiteracy (Palestinian women are among the best educated in the Middle East) have not had the effect typically seen in demographic transitions (Courbage, 1995). The low mortality rates and improvements in child health in Palestine similarly challenge the hypotheses that holds that with reductions in mortality follows lower fertility (Pedersen, Randall, & Khawaja, 2001). The evidence for an atypical fertility pattern indicates that something else is an influence (Fargues, 2000; Pedersen et al., 2001). Demographic conundrum The high fertility and lack of obvious explanations leads Pedersen et al. to label fertility in Palestine a demographic conundrum (2001:212). As one often quoted explanation for this demographic conundrum, Pedersen et al. turns to the unique political history of Palestine. In their data, they notices a decline in the fertility rate in the West Bank that stopped with the first intifada, leading them to draw the conclusion 9

Fecundity is the demographic term used to describe the biological capacity to reproduce.

13

Beyond Numbers: Political Fertility in Palestine that this demographic conundrum can be explained by political factors (Pedersen et al., 2001:121). In accordance, Fargues states that the explanation for the divergence of fertility rates between Palestine and Israel and between the West Bank and Gaza, as well as the irregularities compared to the common understandings of a fertility transition, is politics - the political change of the Intifada (Fargues, 2000). It is these hypotheses that state that due to political factors the importance of having children and increasing population numbers rises and therefore the impact of, for example, education loses weight while political factors gains importance. Fertility on the micro-level According to Fargues, conflict-related aspects impact fertility and the decision to of have children in the private domain (Fargues, 2000), thus making the micro-level important. A complex web of the role of aid and political organisations mitigate the impacts of the economic burden of having children in Palestine. In addition, the very low levels of female employment despite the level of education and the atypical urban, life with curfews and few opportunities for exposure to cultural globalisation are factors connected to the conflict and of influence to fertility on the micro-level (Fargues, 2000). At the same time, political understanding of demography growth as the Palestinians’ most potent weapon has lead to Palestinian authorities officially encouraging women to have more children (Bosmans et al., 2008). Pronatalism10 has become a part of popular resistance towards the Israeli occupation, exemplified in reinventing the value of motherhood politically by making mothers feel like ‘mothers of the nation’ (Fargues, 2000). Another hypothesis of the conflicts impact of fertility is that a resurgence of political Islam can explain high fertility, yet this is more debated and less supported by research (Fargues, 2000). The widespread understanding of the Palestinian case of fertility linked to the conflict is unfortunately often interpreted as either a threat or a weapon (Giacaman, Abu-Rmeileh, Mataria, & Wick, 2008). This dichotomy does not leave room for contextual factors or the inclusion of other aspects that can be of importance both for policy as well as families and women giving birth to Palestinian children (Giacaman et al., 2008). A study finds that family planning has been made subordinate to challenging the ongoing political violence, and the dominant reproductive role of the woman is for the national struggle (Bosmans et al., 2008). A brief presentation of 10

Pronatalism is the promotion of expansive human reproduction.

14

Context historical development of population policies is provided by Jad et al. that draws up the pronatalist view of population growth to achieve liberation, the health movement starting in the 1970s with providing family planning and the antinatalists oriented towards population control (Jad, Johnson, & Giacaman, 2000:153-4). One key study of family planning is that of Palestinian anthropologist Rhoda Ann Kanaaneh. She conducted a study on political demography amongst Palestinians in Israel that casts light on fertility understandings of Palestinians and finds that reproduction has been politicised and maternity nationalised (Kanaaneh, 2002:22). She finds a number of aspects of modernity, traditionalism, and nationalism influence the fertility decisions. The understanding fertility in Palestinian society is highly focused on demographic data and surveys, to try to estimate the predictive power of different factors measured quantitatively. However the conflict seems to play a role in a much more complex manner than quantifiable variables will be able to unfold. Hence, further qualitative research on fertility is being requested from numerous scholars (Khawaja et al., 2009; Courbage, 2011b; Giacaman et al., 2008; Giacaman et al., 2008).

2.2

Family planning

Ensuring access to family planning is one of the main tasks of health systems. Family planning is defined by the World Health Organisation (WHO) in the following manner: “Family planning allows individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births. It is achieved through use of contraceptive methods and the treatment of involuntary infertility. A woman’s ability to space and limit her pregnancies has a direct impact on her health and well-being as well as on the outcome of each pregnancy.“ (WHO, 2011). The benefits of family planning for the survival and health of mothers and children are well-documented. One third of maternal deaths globally could have been prevented by the use of contraception by women that wishes to postpone or to cease childbearing (Cleland et al., 2006). Especially spacing in between births brings health and survival benefits for children. Studies shows that 1 million of the 11 million deaths of children under five years of age on a global scale could have been averted had all interbirth intervals of less than two years been eliminated (Cleland et al., 2006). Also the benefits of access to and use of family planning in relation to poverty reduction, enhanced education, and gender-equality is highlighted in the literature (Cleland et al., 2006). Family planning as a method to be in 15

Beyond Numbers: Political Fertility in Palestine control of ones own fertility is stated as a fundamental human right. In Article 16 of the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) it is declared that states must ensure that men and women have, “[t]he same rights to decide freely and responsibly on the number and spacing of their children and to have access to the information, education and means to enable them to exercise these rights” (CEDAW, 2012). Both the right to decide the number of children as well as the timing is thus mentioned, as well as access to family planning services. The treatment of infertility11 is part of the definition of family planning12 by the WHO and stated in ICPD.

2.3

The setting of the refugee population in the West Bank

In the West Bank 34% of the population are registered refugees (UNRWA, 2011b). The refugee situation of the Palestinian refugees is unique in relation to other refugee populations. It is nearly 64 years since the uprooting that followed the nakba13 that according to historian Ilan Pappe uprooted close to 800,000 Palestinians over the course of six months from their homes and villages in what is now Israel (Pappe, 2006:xiii). For the Palestinians, the question of the right to return shapes collective memory and identity (Giacaman et al., 2009), though the majority of the refugee population has never set foot in the land from which they originate. The refugee women of this study all live in Kalandia camp, a camp that lies in the outskirts of Ramallah in the West Bank and was established in 1949. Approximately 11,000 registered refugees live in an area of 0.35 km2, and most originate from Lydd, Haifa, Jerusalem and Hebron (UNRWA, 2011a). Kalandia is one out of nineteen refugee camps in the West Bank, one of three camps in Ramallah, and is situated adjacent to the main checkpoint on the main road from Ramallah to Jerusalem (UNRWA, 2011a). From the main entrance to the camp, the Separation Wall and the checkpoint are visible and many Palestinian demonstrations opposing the occupation start from this entrance. Within the camp, UNRWA runs one health clinic. This clinic offers, amongst other services, mother and child health (MCH), family planInfertility is defined by WHO as: “the inability to conceive a child. A couple may be considered infertile if, after two years of regular sexual intercourse, without contraception, the woman has not become pregnant (and there is no other reason, such as breastfeeding or postpartum amenorrhoea).”(WHO, 2012). 12 In this thesis I use the term family planning entail both contraceptives and infertility treatment unless explicitly stated otherwise. 13 Nakba means ‘the catastrophe’ in Arabic and is the term used by Palestinians to refer to the events of 1948. 11

16

Context ning programs and provides services to registered refugees living within the camp or outside. As the Israeli authorities consider this area part of Greater Jerusalem (despite the Separation Wall cutting off the camp from access to Jerusalem), Kalandia camp remains under Israeli military control (UNRWA, 2011a). 2.4

The health care setting of Palestinian refugees in the West Bank

There are four main providers of health care in Palestine: the Palestinian Ministry of Health (MoH), UNRWA, NGOs (both Palestinian and international), and the private sector. The first health plan for Palestine came into being in 1994 after the establishment of the Palestinian National Authority (PNA) in 1994 with the aim for regulating and integrating the services of these four service providers (Mataria et al., 2009). The amount of donor aid coming to Palestine is substantial, even described as “one of the largest ever undertaken by the international community”, and 8% of the aid goes to health (Giacaman, Abdul-Rahim, & Wick, 2003:64), leading to the expectation that the international community’s discourse will resonate within the health services provided for Palestinians – and especially so for the refugees under the mandate of UN. The MoH started offering family planning services in two clinics in 1995, just after the establishment of the PNA in 1994. They do not have an explicit policy on family planning, nevertheless they conduct family planning services in 150 MoH primary health clinics today. UNRWA started providing their family planning services much earlier and has a long history of providing these services. UNRWA has a policy on family planning amongst other services. This document was first applied in 1995 and has been revised latest in 2009. A national committee for family planning, headed by the MoH, secures the collaboration and coordination of the family planning services of the MoH, UNRWA and the major NGOs. UNFPA funds the reproductive health services in the West Bank, and purchase the family planning commodities. UNRWA runs 41 primary health care facilities in the West Bank, out of which 40 facilities offer MCH and family planning. These clinics provides services to 848,000 registered refugees (out of which 24.3% live in UNRWA camps) (UNRWA, 2011b). The coverage for antenatal care (ANC) is 51.3% (UNRWA, 2011b), while the coverage rates for deliveries at health institutions and for post-natal care (PNC) are both much higher, 99.6% and 81.9% respectively, indicating trust in the UNRWA health services by the mothers. The prevalence of usage of modern contraceptives among 17

Beyond Numbers: Political Fertility in Palestine women of reproductive age that are utilising the UNRWA MCH services is 59.1% (UNRWA, 2011b). At the end of 2010, 20,814 were registered as users of modern contraceptive methods through the UNRWA health clinics, with the most preferred method being intra-uterine device (IUD) (58.3%), contraceptive pills (23%), and condoms (15.6%) (UNRWA, 2010). Before proceeding to the analysis of fertility in Kalandia refugee camp, I present my methodology.

18

Methodology

3

Methodology

Public health as an interdisciplinary field draws from a variety of disciplines in shaping its independent academic position, thereby placing itself in the intersection between different epistemological positions. In this chapter I present my methodological choices and justify my particular approach. The point of departure for this chapter on methodology is that scientific practice consists of two dimensions; theory and practice, which are constantly mutually influential and the chapter is therefore divided into two parts. First is an epistemological positioning and second is the operational dimension of what I have done in practice, both in the fieldwork as well as in the analytical process. 3.1

Methodological point of departure

I have conducted a qualitative study: an ethnographic field study of fertility in Palestine. In order to shed light on political fertility as a concept amongst refugee women of Kalandia camp and professionals working with family planning in the West Bank, I have chosen to spend nearly two months on fieldwork in Palestine. With this methodological choice I disclose my ontological position. In line with the idea of social constructivism as laid out by Esmark et al. (2005:24), my objective throughout the process has been to question current perceptions within the literature on political fertility with a critical aim of challenging what appears as given. By approaching my field with inspiration from social constructivism, I gain a chance of investigating how fertility is constructed and in what ways it is constantly reproduced, changed and challenged in social practice (Jørgensen & Phillips, 1999:170). An ontological positioning is necessary within this study at the intersection of demography and ethnography. I subscribe to what anthropologist Klaus Høyer calls a ‘fluid’ ontology as opposed to the stable ontology seen in positivistic medical science (Høyer, 2011). This ontological point of departure entails viewing fertility, for example, as something dynamic and relational that cannot be described (purely) by numbers and statistics, and my main interest lies with the understanding of the social dynamics that shape understanding of fertility. Yet at the same time, I do not subscribe to a entirely fluid ontology where nothing is stable (Høyer, 2011), and I have not conducted a theory-driven study. There are regularities in the world and these should 19

Beyond Numbers: Political Fertility in Palestine not be overlooked by operating in narrow perspectives where close to nothing can be compared (Høyer, 2011). Quantifiable measures of fertility also express important knowledge about the world. Fertility rates and research on determinants are forms of meaningful statements on fertility, and they are neither more nor less important than qualitative statements. Rates and quantifiable measures are on the other hand also constructed and defined with a clear distance from the local actions and actors and can from such a point of view be seen as one end of a continuum with qualitative data at the other end. The fact that I have conducting this ethnographic study of fertility should not be read as a positioning of my research within the divide between the quantitative and qualitative sciences, as I do not perceive such a division as productive. Demography is a broad research field, often understood within a positivistic ontology, but also includes contributions from social studies as well as economical, statistical and medical research. With this study, I aim to show the relevance of including the actions of social actors in the field, leading me to a somewhat different focus to than found in the body of literature on fertility in Palestine. The ontological point of departure influences my understanding of theory, as theory mirrors different perceptions of the world (Høyer, 2011). In this thesis I understand theory as what Høyer terms a ‘can opener’14, understood as a tool to open up analysis or a frame of reference to help produce an orientation in a field (Høyer, 2011). In signifying this understanding as a type of tool, it is implied that other tools could have chosen and other results obtained. The theoretical and methodological choices shape what we see and what we can say about reality (Fredslund & Dahlager, 2005). Any phenomenon can be looked at in many ways methodologically and theoretically, and in this ‘can opener’ understanding theory is in some ways similar to inspiration (Høyer, 2011:24). Stemming from my ontological position, also comes the fact that this thesis is not an evaluation of health services nor accordance to policy. Neither is it a judgment of right and wrong. Theoretical concepts that I deem relevant and helpful in the analysis will be used, but they may not relate to one ‘grand theory’. The specific concepts used to open up the analysis in this thesis will be laid out after a presentation of the operational dimension of the study. This structure is chosen to let the reader follow my analytical path as close as possible.

14

The term is translated from the Danish word ‘dåseåbner’

20

Methodology 3.1.1

Ethnography

The methodological approach employed in this thesis is qualitative, namely ethnography, as my interest in the field of fertility in Palestine originates from looking at social and political relations and moreover, as a consequence of my epistemological point of departure. I have conducted numerous qualitative interviews in combination with extensive participant observation and document analysis carried out during my fieldwork in Kalandia and Ramallah. As opposed to the aim of reducing or eliminating the influence of the researcher on the data, the qualitative method tries to make use of this influence to enquire into this construction of data (Bjerg, 2011:56). An important quality of ethnographic fieldwork is that it allows the researcher to be surprised and to learn something new from the reality of the field (Tjørnhøj-Thomsen & Whyte, 2011). This also means that the researcher must be open to changes and revise the methodology or analytical categories as a result of the unpredictability of the field and the empirical reality (Fredslund & Dahlager, 2005). The data is created within social relations and requires participation of the researcher. The methodology is therefore more than a set of rules and techniques, or as anthropologist Kirsten Hastrup phrases it: “the ethnographic method is performative, rather than procedural” (Hastrup, 2004b:419). This makes the influence of the researcher, and all other circumstances of the fieldwork, an inevitable part of the material. Yet, as the material hence becomes enormous, the researcher must take a selection for analysis to turn the empirical material into knowledge (Hastrup, 2004a). The knowledge that can come from such data is therefore, as Donna Haraway puts it, always situated, positioned and partial (Haraway, 1988). Ethnography “demands reflexivity, i.e. a critical attention to and a disclosure of the choices, conditions and social processes that influences the empirical material and the final production of knowledge” (own translation) (Tjørnhøj-Thomsen & Whyte, 2011). According to anthropologist Roger Sanjek, reliability in ethnography is not possible (Sanjek, 1990) due to the social influence of the researcher and the social relations established throughout fieldwork. Therefore can fieldwork never be reproduced (Tjørnhøj-Thomsen & Whyte, 2011). Instead, what is at the core of an evaluation of ethnography is validity. One criterion for ethnographic validity is to openly put forward the theoretical arguments for the choices made in ethnographic work, coined ‘theoretical candor’ by Sanjek (Sanjek, 1990:395). Theory should be used to give ethnography meaning and purpose and to avoid the study of ‘everything’ (Sanjek, 1990). This is in line with the 21

Beyond Numbers: Political Fertility in Palestine understanding of the theory I have applied in the analytical chapters. Sanjek put forward other two criteria. The second is that of ‘the ethnographer’s path’. In order to assess the validity of the ethnographic work it is necessary to be able to follow the fieldwork as closely as possible, making detailed accounts necessary. The third point is similar and focuses on the field notes’ link to ethnographic knowledge (Sanjek, 1990). With these and the quality requirements for qualitative research set forth by Fredslund and Dahlager I discuss my research process after presenting my analysis. In the following I give an account of my path to enable others to question my methodological choices and understand my process. 3.2

Methodology: operational dimension

The operational dimension of my methodology began prior to the fieldwork in Kalandia refugee camp and Ramallah. I have conducted a thorough literature search to prepare my fieldwork and inform my analytical process upon returning and during the fieldwork I conducted interviews and participant observation. I have chosen these methodologies as a result of my epistemological point of departure as well as with the aim of challenging my own learning process. I will begin by describing the initial literature search. 3.2.1

Literature search

I have used existing literature to get acquainted with the research in order to see where my research could contribute to the current knowledge on fertility in Palestine and to facilitate the analytical phase. The literature search described below has been a vantage point as well as a source to grasp the research field and obtain contextual knowledge. Furthermore, it has been an iterative process as I have returned and consulted with other studies and theory throughout the research process. Early in the research process, I conducted a thorough systematic literature search to understand the scope and character of the current knowledge base of fertility in Palestine. To ensure an extensive search and a variation of scientific perspectives I carried out the search in several databases representing publications from different scientific disciplines (Pubmed, Sociological Abstracts, EMbase, Social Sciences Citation Index). The search strand used for Pubmed was: (Palestine OR occupied Palestinian territory OR occupied Palestinian territories) AND ("Population Growth"[Mesh] OR "Birth

22

Methodology Rate"[Mesh] OR "Fertility"[Mesh])15 and similar search strings were adapted for the other databases. I have not limited the searches to the West Bank, as many of the studies I have found relevant and useful are conducted with Palestinians residing in neighbouring countries. These searches did not provide me with a large number of articles (for example the Pubmed search gave 13 articles and Sociological Abstracts 12), yet some of these articles gave a thorough overview of current knowledge16. By consulting the references of all articles and reading related articles I gathered an extensive amount of literature. While in Palestine I conducted a systematic literature search at the library of the Institute for Community and Public Health (ICPH) at Birzeit University to find locally published literature in Arabic or English. This search resulted in two relevant Masters theses, useful for giving perspective on my own approach and findings. Before starting the fieldwork I also conducted a background interview with a researcher on fertility, Dr. Abu-Rmeileh at ICPH, to gather further information on current research on fertility in Palestine as well as her insights into this policy- and health- area. Moreover, through academic networks in Ramallah I have been recommended other relevant literature during my fieldwork (allowing access to unpublished, ‘grey’ literature, otherwise unobtainable) and by my supervisors. The systematic literature search constitutes the basis for the review of existing literature on fertility in Palestine, presented in Chapter 2. It also informed the development of my problem statement and interview guides (as discussed later in this chapter). 3.2.2

Ethnographic fieldwork

I conducted my ethnographic fieldwork in September and October 2011 in Ramallah in the occupied West Bank during some nationally important times. During the time I did my fieldwork in Ramallah, the president of PNA, Mahmoud Abbas went to New York to seek international support from UN member countries for recognising Palestine as member state number 194, causing large celebrations and demonstrations in the streets of Ramallah as well as enthusiasm and intense discussions among Palestinians.

This search was conducted for the first time on 16th of July 2011. Especially relevant was the Lancet series of meta-studies on Health in the Occupied Palestinian Territory from 2009. 15 16

23

Beyond Numbers: Political Fertility in Palestine My collection of data resulted in four interviews at policy-level with policy planners, eight interviews with women in Kalandia refugee camp and more than a week’s participant observations in the UNRWA primary health clinic in Kalandia camp including informal interviews with clinical staff and a collection of written educational material available at this clinic (See Appendix I). The empirical material and choices leading to this data collection will now be presented. An essential feature of fieldwork is the creation of room for new understanding of the field, which also demands an ability to constantly revise the methodological approach, problem statements and analytical categories (Tjørnhøj-Thomsen & Whyte, 2011). I attempt to present these ongoing changes throughout the description of the process. 3.2.2.1

Choosing analytical group and levels of entry

Approaching the empirical field renders a degree of limitation necessary, as I have to choose what part of the field to conduct my investigation within. The analytical object contains a theoretical inspired selective attention towards the empirical field (Tjørnhøj-Thomsen & Whyte, 2011), and I have chosen to focus my study of political fertility in Palestine on the refugee population. In choosing the actual study sites both my contact network in Ramallah and the literature search played major roles. Through an internship with a Palestinian NGO in spring 2011 I established a network allowing for my entry into the health policy world of the PNA as well as UNRWA. I worked closely with the director of the Health Program of UNRWA in the West Bank, Dr. Ummayeh Khammash, which allowed me to access an UNRWA clinic. He has worked in the field of reproductive health in Palestine for over two decades and functioned as a central gatekeeper to my research field. Choosing entry sites: refugee population and Kalandia camp In the literature on political fertility a hypothesis that refugees by virtue of their uprooting are the most political aware Palestinians is widely held (Khawaja, 2003). Quantitative analyses of fertility are often split by refugee status and substantial changes in fertility has been seen amongst refugee populations living in camps in the West Bank (Khawaja, 2003). Therefore I chose to follow the health encounters for refugees in an UNRWA clinic and conduct my interviews with mothers in the same refugee camp. I chose Kalandia camp since it, in Dr. Khammash’s words, is “very politicized because of the nearby checkpoint and the many problems with the Israelis the residents in 24

Methodology this camp [have] experienced”. Moreover, my presence in the UNRWA clinic of Kalandia camp would not interrupt the staff in providing services (they do not have as high a patient load as for example Al-Amari camp, another camp situated in Ramallah).

Figure 3. The entrance to the UNRWA health clinic in Kalandia camp, situated at the main entrance to the camp. Photo LNH, September 2011.

Choosing multiple levels of entry I wanted to look at different political understandings of fertility as they appear at multiple levels, from the personal to the political, and furthermore how these levels are related. This lead me to conduct my ethnographic study at three levels: with refugee women ‘acting’ out fertility as mothers, by observing health professionals acting out policies related to fertility as well as with relevant policy planners. From my epistemological point of departure, I view fertility as a concept constantly constructed through the relations in which it occurs, and so my methodology must accommodate being able to see this (Høyer, 2011:34). I have therefore studied these three levels, all entailing different relations to the concept of fertility, to be able to shed light on such relations and constructions. The entry points to my interviews – a policy level and a level of the mothers in Kalandia – were chosen in order to obtain a nuanced understanding from people in some way representing each end of a spectrum of politics on paper and politics on the ground. I chose the clinical practice as another entry point stemming from an assumption that this would reveal information not obtainable through the interviews. 25

Beyond Numbers: Political Fertility in Palestine Observing practices can both disclose new information and verify information from interviews. Moreover, the clinic can be thought of the link conducting interpretation of health policy to women’s lived lives and vice versa. I therefore conducted participant observations of the world of the clinic to yield insights into discrepancies between the two levels of policy and everyday life. This fieldwork was in other words multiple-contextual, creating a broad spectrum of insights (Tjørnhøj-Thomsen & Whyte, 2011:103). 3.2.2.2 Positioning I come to the field as a Danish female student and not a mother, representing a Western understanding of fertility, family planning and women’s rights. I thus position myself within the field and bring with me a set of related understandings and my approach is influenced by these pre-assumptions. Moreover, a positioning of me by the field is unavoidable. The informants see me in this light, which influence their statements and thereby our positions become part of the empirical data. The informants have probably only said the things they wanted me to hear; or what their mother-in-law present in the adjacent room was allowed to hear; or what they believe to be most suitable for their agenda. This is a classic situation in ethnographic research which is especially evident in fieldwork of a short span as mine. Two of the mothers gave me the impression that they expected me to help them financially, revealing their motivation for taking part in the interview. This positions me as a foreign aid worker and them as a possible recipient, rendering certain statements more opportune than others. Therefore, all the empirical data should be seen in the light of the positioning of (all) those involved. 3.2.2.3 Participant Observation I conducted participant observations at the UNRWA clinic in Kalandia camp, where I also sampled the mother informants. I stayed in the clinic a total of seven days fulltime in addition to the many times I stopped by. Participant observation is the methodological strategy of ethnographic fieldwork, done in order to look at the observed’s social life on the observed’s premises (Tjørnhøj-Thomsen & Whyte, 2011). The empirical data that the participant observations yield depends on the way the researcher approaches this social life, the balance between participating and observing (Tjørnhøj-Thomsen & Whyte, 2011). I wanted to see the practices surrounding clinical encounters for women and contextualise the 26

Methodology understanding at the policy-level and amongst women of how fertility and family planning is conducted. In this way I perceive the clinic as linking element between policy and the reality of the women. Access To get to share the space of the clinic and observe the encounters I had to be allowed access by the different staff in the clinic, and this access had to be negotiated again and again (Tjørnhøj-Thomsen & Whyte, 2011). First, the negotiations to access the clinic went through Dr. Khammash. This process went smoothly and took only a few days. I was warmly greeted within the clinic. By offering my help in any situation I gained trust and a positive attitude towards myself and my presence and my person. All staff members were welcoming and interested in sharing and talking, and in very short time I became part of the team. By participating in manual work and sharing joint physical tasks, I became a ‘player’ on their team and could easily take part in most tasks within the clinic, despite my limited Arabic skills. This provided me with observations of the way clinical encounters are conducted, albeit of course given my presence. Observational strategy My strategy was to be involved and actively participate in as much work as I could in the clinic, which allowed for an openness and access, yet the field also set limitations for what I could participate in as I am not trained medically. Offering a hand also meant I felt more comfortable myself, as I had a role to fill, or if there was nothing I could do but observe, it did not feel as if I was ‘in the way’. This made the shared time and space comfortable for all. As the clinic was new to me and I did not know what to expect, I chose to mainly use an open observation strategy, in which one in an unknown context attempts to observe and register ‘everything’ (TjørnhøjThomsen & Whyte, 2011). I tried to be aware of the physical setting, the people that were present, the activities, the relations and the interactions. I drew up a list of what to be aware of before starting the fieldwork (See Appendix II). I also used the strategy of observing ‘bumps’. As an example from the clinic, I reacted to practices that seen from my perspective were a lack of privacy, yet it was not perceived as such by either staff or patients (seemingly). Privacy is subjective concept, relying very much on local cultural norms and practices explaining why a practice that was not seen as problematic in the context, was provoking to me (something I discuss in Chapter 6) 27

Beyond Numbers: Political Fertility in Palestine and stood out from other observations as a ‘bump’. The things one observes will be shaped by ones point of departure, and this should yield methodological reflections about what one sees, where one observes from and what one looks for (TjørnhøjThomsen & Whyte, 2011). Field notes The first step in transforming participant observations into data and knowledge is field notes. I took such notes from the very beginning, to describe what people do and not merely what they say. What seems trivial in the field often becomes important later on, making such notes central (Tjørnhøj-Thomsen & Whyte, 2011). In the clinic, I took key word notes, and upon returning home I wrote a log of the day’s observations, as recommended in classical ethnographic field studies (Wolcott, 1994). 3.2.2.4 Interviews I conducted semi-structured interviews with policy planners, mothers, and clinical staff. Semi-structured interviews enable the collection of qualitative data in which research areas are elucidated by the informants’ own meanings and perceptions of the world (Christensen, Nielsen, & Schmidt, 2011). The conversations I had with the clinical staff took the form of semi-structured interviews as well as what can be characterised as informal conversation. The latter is defined by some scholars as an integral part of participant observations, showing the grey area between participation and interview (Tjørnhøj-Thomsen & Whyte, 2011). Informants In order to choose my informants I used purposeful sampling to gain an empirical material as nuanced as possible, yet two very different strategies were employed: sampling policy informants based on an assessment done with Dr. Khammash of the key actors for policies on family planning, while sampling mothers from the clinical setting. Policy informants The target population for the policy interviews was those professionals in positions that enabled them to influence policy on fertility both in the PNA and UNRWA. The political nature of fertility in Palestine is not present only in one single family planning program or clinic and therefore to understand the dynamics on a policy-level, a number of actors must be represented. Within the scope of this project, a full ac28

Methodology count of all policy-makers is neither feasible nor necessary to obtain an insight into the work of fertility policy in the West Bank. A strategic sampling of maximal variation was employed (Christensen et al., 2011:71), and with Dr. Khammash I conducted an assessment of the key actors and chose to interview the Director General of Women’s Health in the Development Directorate, MoH as she has been with MoH since its establishment in 1994 and the Acting Director General, Directorate of Social Sector Planning, Ministry of Planning, MoP as he was one of the initiators of a Population Committee. The chosen PNA informants are influential within fertility and family planning in the PNA, and the PNA sets the scene for all Palestinians in the West Bank. I have hereby deemed the PNA’s position relevant to the understanding of fertility amongst the Palestinian refugee population as the refugees also constitute ‘Palestinians’ and are an important part of Palestinian identity. However, while the PNA is influential for the understandings and official discourse, it is UNRWA who provides the health services to the refugee population, and it is UNFPA that funds family planning services. For this reason I also chose to conduct interviews at policy level with both of these organisations. All policy interviews were conducted in English. Mother informants The target population for my study was Palestinian mothers. As my epistemological point of departure fosters an inductive approach, it is important for me to hear the first-hand accounts of women who give birth to Palestinian children. By giving women a place from which to speak about fertility, I allow them to challenge the “powerful stereotype of the passive and ignorant Third World woman” (Kanaaneh, 2002:256) as “reproduction is precisely the arena through which many people around the world negotiate the overwhelming changes sweeping through their lives” (Kanaaneh, 2002:256). An operational subgroup was of course necessary and I chose to focus on refugee women in Kalandia camp. I sampled mothers in the reproductive age, preferably in their mid-20s or 30s as they presumably are considering numbers of children and pregnancies, and they personal experience related to fertility and presumably also family planning. I aimed for variation with regards to number of children, education, and employment. All were currently living in the camp. I established contact through the clinic as a way of narrowing down the possible informants. As the clinic is used for antenatal and postnatal care I interpreted this as trust in the clinic, for which reason sampling from its patients is feasible. I sampled the refugee women either from women who attended the services while I was present or contacted them through the clinic staff. At 29

Beyond Numbers: Political Fertility in Palestine the beginning of the fieldwork, the sampling was random, but after the first interviews I tried to set up interviews with women employed outside the home, in order to gain maximal variation in relation to employment. I did not succeed and as only a minority17 have jobs, I accepted this. I then asked one of the nurses to help find women who had close family members who were killed or had been or currently were imprisoned by the Israelis (translated into having “mushkile”, Arabic for ‘problems’). In this way two informants are theoretically sampled, in order to shed light on other aspects of the research topic than given by my previous informants (Christensen et al., 2011). In one of the eight interviews with mothers, the husband was present and has become part of the empirical material. We had set up an interview with a 17-year old new mother and her husband was present expecting the interview to be with them as a couple. They had just had their first child a week prior to the interview, and we chose to let him be part of the interview. The husband did by far the most talking in this interview, which has meant that the empirical material from this interview has not been used as much as the other interviews to shed light on the perceptions of mothers. All women were interviewed once and interviews were conducted in the homes of the women in order to foster a trusting and open atmosphere for the conversation. I have made the mothers names anonymous. These interviews were conducted with an interpreter, a Palestinian woman fluent in Arabic and English (see below). Interview guides Before initiating data collection I prepared interview guides used to interview the various informants (see Appendix III). The transformation of the questions of the analytical inquiry into the questions actually posed to the informants shapes the final empirical data, and thereby the analytical final frame. This operationalisation of the research questions results in an idealised model of the interview process, a process that in practice will differ in the order of the questions as well as the way of posing the questions due to the dynamic nature of interactions between researcher and informant (Christensen et al., 2011). The interview guide should both help create a trustworthy atmosphere during the interview, to stimulate the informants to speak of their experiences (by Kvale termed the question’s dynamic dimension), and an ap-

The percentage of women with employment inside Kalandia camp is unknown, and according to Dr. Khammash such data does not exist at camp-level. 17

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Methodology propriate scope of questions, to ensure that the interview covers all the necessary research themes (the thematical dimension) (Kvale, 2009:151). As I had a pre-assumption that the topic could be seen by the mother informants as sensitive, I chose to put most emphasis on the development of this interview guide. The way I chose to present what we would talk about framed the thinking of the participants while positioning me, making the introduction crucial. I chose to disclose my purpose as a study about having a family in Palestine, without emphasising the political aspect of the study. I told the women that the interview would be about having a family in Palestine and fertility, trying to keep a balance of honesty while keeping the matter as specific as I could. I tried to pose concrete as opposed to abstract questions to start off with in an attempt to position my informants in their role as experts and thereby create a somewhat equal relation given our different roles. The opening question must be thought through carefully (Christensen et al., 2011) and a good starting question that I often used, was “Tell me…” (Morse & Field, 1995:91). As I had an idea that some of the women informants could have a hard time answering questions in areas they perhaps seldom reflect upon, I found it essential to prepare the use of probing and explorative questions. These are questions within what Kvale terms the dynamic dimension of the questions and often “Can you tell me more about this?” is used to show interest and gain detailed accounts (Christensen et al., 2011). At the end of the interview I asked if the informant had questions or anything to add, which often led to an understanding of their motivation for participating or their perceptions of the study (Kvale, 2009:149). Such information is part of my empirical material and reflections upon my findings. In order to ensure a flow in the conversation, to test whether my formulations made sense, and to become aware of my strengths and weaknesses as an interviewer, I pretested my interview guide for the mothers with a former colleague, a Palestinian mother of three. From this pre-test and throughout the fieldwork I revised my interview guide to improve its comprehensibility. I experienced problems with lack of detail and a feeling of superficiality in the first interviews with the mothers. I tried to change my interview techniques by putting more emphasis on using silences, acknowledging through sounds and body language and thereby giving permission for the informant to reflect and then speak (Morse & Field, 1995:102). Interview guides for policy planners 31

Beyond Numbers: Political Fertility in Palestine The development of the interview guides for interviews with policy planners was conducted with similar considerations, yet these were not assumed to be as personally sensitive, I posed some questions within these interviews that could have been seen as more confronting. These interview guides served more as a help to keep the interview on track and for me to remember all aspects, rather than a method for getting them to speak. 3.2.2.5 Working with an assistant I had to hire an assistant, as I do not speak Arabic and most of my informants do not speak English. This of course influenced the empirical data, yet it opened doors that would never have been possible without an interpreter. Through one of my supervisors, I got in contact with Maysoon Bseiso, a 50-year old woman from Ramallah with a recent MA degree in Public Health from Birzeit University. She speaks English very well and interpreted all interviews with mother informants from Arabic to English. Our relationship was crucial for the data I got from the field. She functioned as a gatekeeper to the field and became the lens through which I could see the field. Her understanding of my aims, her choice of words and approach influenced the meetings with the women. Moreover, the presence of the two of us made our stepping into another person’s home even more intrusive than had it merely been one interviewer. As an assistant, Maysoon was quite actively involved in the interviews and would even reprimand informants for statements she disagreed with politically. As an example, when a young boy told me during an interview with his mother that he wanted to become a martyr at the age of 20, Maysoon reacted by telling him off and saying in a very direct manner to his mother that she does not believe that this is the proper way to show resistance towards the Israeli occupation. Moreover in the interview situations, not every statement was translated verbatim. I chose to instruct Maysoon to translate exactly what was said, as I believed this was important for my data, and this also became the practice as we proceeded with conducting interviews. Yet not everything was translated which means that golden opportunities for asking about additional details were missed. This is a common pitfall when interviewing using an interpreter (Morse & Field, 1995:103). The frustration is probably also very common. On the other hand, Maysoon contributed with a delicate sensitivity about when and how to ask for personal details, creating data that could not have been 32

Methodology possible had I been alone. As an example, a mother told us again and again during an interview that she did not like to use family planning methods advised by the UNRWA clinic as she had her own method. After she had stated this several times, we wanted to know what this method was, and Maysoon asks if this entails sexual abstinence. Her way of posing such a delicate question was to ask whether the woman treats her husband as if he was her brother, a very clever and delicate way of asking such an intimate question. Spending time on understanding the project, discussing every question in the guide and reflecting on each finished interview enabled us to improve the collaboration and obtain more detailed accounts in which the informant got more time and space to reflect during the interviews. Yet some of the interviews with women took more the form of a conversation between a few Palestinian women with me as the observer, rather than a semi-structured interview with an interpreter. It took the first few interviews for us to know each other, to understand the aim and for me as a young student to position myself as the researcher in relation to a 50-year old middleclass woman with an MA degree in Public Health. I prioritised spending time with her to discuss the project, the aim and the methodology. We discussed the project on an almost daily basis from before we started interviewing until I left Ramallah. Her inputs on methodology as well as cultural and social aspects were invaluable. I have chosen to view her input, her reflections and her contributions as part of the empirical material and she will therefore be referred to in my analysis. 3.2.2.6 Processing of interviews Immediately after every interview I wrote notes on the content of the interview as well as methodological aspects. In all but two interviews (UNFPA, UNRWA) I was granted permission to record. During every interview I took notes, and during the two interviews where I was not granted permission to record I took comprehensive verbatim notes. This was also the case for things said in an interview situation when the dictaphone was not turned on. All interviews conducted in Arabic and translated to English were transcribed by my assistant and read through by me. As early as the transcription process a reduction of data and a level of analysis occurs (Christensen et al., 2011), and as this process was out of my reach some observations were lost. This is unavoidable, yet I tried by means of talking every interview through with

33

Beyond Numbers: Political Fertility in Palestine Maysoon to be part of as much of the process as possible. I transcribed all policy level interviews. 3.2.2.7 Documents I have chosen to include brochures on family planning from the UNRWA clinic as part of my material. 3.2.2.8 Presentation of empirical material All my empirical data is presented below in Table 1, and further details of the data collection process can be seen in Appendix I. All material was treated equally in the analytical process. 3.2.3

Analytical strategy

My analytical strategy describes the operational level of the analytical work and I will here argue for the choice of approach. My analytical strategy is governed by my rich empirical material rather than theoretical concepts. As I went through the major effort of collecting data in Kalandia camp, involving a range of people, organisations and a clinic, I owe it to the field, to the data, to the informants and to knowledge production to let the data have space. I let the themes emerge from a bottom-up perspective, rather than fit the material into a theory or showing a theory to be wrong or right. As explained previously, theory is used as a way of opening up my material and to unfold themes that emerge from the empirical material. After returning from fieldwork the analytical process started in practice with an analytical read-through of the three components of data from the different arenas (mothers, clinic and policy) that I thought of as having the most analytical substance in that they entailed varied perspectives on fertility. Analytical read-through should be understood as a process in which I noted down in the margin which themes came up, the choice of words, what was not said etc. This gave me preliminary themes and an initial overview of the material.

34

Methodology Table 1. Presentation of empirical material Type of data Interviews

Informant Woman A Woman B Woman C Woman D Woman E Woman F Woman G Woman H MoH MoP UNRWA UNFPA

Kalandia Clinic Informal Kalandia interview Clinic Observations Kalandia Clinic Written ma- Kalandia terial Clinic UNRWA Photos

UNRWA

38 years of age, 4 children 36 years of age, 5 children Couple: woman: 17 years of age, man: 29 years of age. 1 child 34 years of age, 4 children 37 years of age, 1 child 34 years of age, 6 children 55 years of age, 5 children 44 years of age, 5 children Director General of Women’s Health, Directorate of Development Acting Director General, Directorate of Social Sector Planning, Ministry of Planning Director of the Health Program, West Bank Reproductive Health Program Assistant Senior Medical Officer

Duration 42 min 56 min 33 min

Language18 Arabic Arabic Arabic

45 min 64 min 44 min 84 min 47 min 60 min

Arabic Arabic Arabic Arabic Arabic English

92 min

English

---19

English

---20

English

35 min

English

Staff nurse On clinical work / reproductive health related work 4 brochures on Family Planning “Maternal Health Record” (folder) “Family file” form

English 7 days

Eng./Arabic Arabic Arabic ----

From here, I proceeded with the remaining material in the same manner and through this process I mapped out all my empirical material. I now had post-its with keywords hanging on the wall of my office. In order for a structure to emerge within the chaos of this mapping of my material I began a process of condensation into categories and then themes (see Appendix IV). For the condensation and abstraction (where condensed text is grouped into themes for interpretation) process I found inspiration in the work of Graneheim and Lundman, (2004), yet I did not find it necessary to applied as many steps. Over several rounds I tried different cross-sections of the material, all searching for themes that triangulate the different informants. Certain analytical points remained and I started writing from these. The themes then All Arabic language interviews interpretated by Maysoon, research assistant. Not recorded with dictaphone, approximately 60 min. 20 Not recorded with dictaphone, approximately 40 min. 18 19

35

Beyond Numbers: Political Fertility in Palestine changed a little, but seemed to cover the material. To ensure an analytical rigor I went back to all the components of empirical data to ensure I had everything belonging to every theme. In this writing up of the themes I have included theory (incl. findings from other studies) whenever relevant and necessary to unfold an analytical point. The forthcoming analysis is not a complete representation of the empirical material, as I have chosen the parts relevant to this analysis and other analytical tools could have been chosen. The epistemological understanding underlying this thesis renders an openness towards the material and reflexivity towards what influences knowledge production necessary (Fredslund & Dahlager, 2005). I have let the empirical material lead the way, rather than my understanding prior to the fieldwork and theory. Reading through the literature before choosing my angle, the notion of son preference came up repeatedly and I decided I did not want to write about this. I thought of it as reactionary way of looking at the Middle East. Yet, while conducting the analysis it soon became clear that my empirical material has a component which is about the composition of the children including son preference. In order to perform this openness, I decided to let the empirical data overrule my ideas of what this analysis should include, and I have included son preference as an analytical point. A similar process is the case for the first theme I will present, infertility; it emerged from the material without me giving it notice beforehand. In a section of the first analytical chapter, I have therefore employed a strategy of describing an especially illuminating case. This is done in order to allow space for the ethnographic data’s details and to let an analytical theme given much importance by my material emerge. By analysing the perspective of those that do not fit the mean or norm (in this case an infertility woman), much can be said of the norm. I have in this chapter accounted for my methodological choice and practice in order for others to evaluate the validity of the following analytical work. Before I proceed to these analyses I will present the major theoretical concepts and important literature which have been used to grasp the empirical material.

36

Theoretical framework

4

Theoretical framework

The theoretical concepts presented here have shaped my approach to the field, my research questions, my methodological choices, as well as the analytical work of thematical condensation and discussion. Theory is used prior to the actual investigations, as well as a way of opening up the material in order to make sense of it (Høyer, 2011:25). This chapter bears the mark of the interdisciplinary element of public health science, as it gathers together theory from demography and sociology. The theoretical concepts presented in this chapter have influenced the problem statement and the analytical line of enquiry and lays the theoretical base of the forthcoming analyses. 4.1

Demographic framework for understanding fertility

In order to present the framework that the forthcoming analytical chapters are build upon, I first give an overview of the factors considered in demography to determine fertility. Demography is the study of populations as dynamic entities which change through fertility, mortality, immigration, and emigration as well as through societal changes and developments (Winckler, 2009:5-6). Demographic research revolves around numbers and statistics, but it does so with input from the social sciences to help explain and understand trends and determinants. Classic theories of population dynamics often focus on the macro-sphere, whereas my ethnographic study adopts a micro-level approach. Nevertheless, macro-level factors such as politics obviously influence the very core of the perceptions of fertility that I look at. Certain understandings of the links between societal development and fertility are pervasive in demography. Under the influence of classical development models, the decline in fertility first recorded in Europe and later spreading to other parts of the world is understood to be due to diffusion of Westernisation and modernisation (Gould, 2009). The classic demographic transition model (DTM) states that fertility is systematically related to mortality rates. Economic and social development cause changes in mortality patterns, and accordingly changes in fertility are driven by such developments (Gould, 2009). Yet variation in the pace of fertility declines shows that not only socioeconomic variables determine fertility. In response to the inadequacy of socioeconomic variables in explaining fertility trends and differentials, Bongaarts and Potter present proximate determinants (1983). Proximate determinants are behavioural and biological factors that explain the causal relation between socioeconomic 37

Beyond Numbers: Political Fertility in Palestine variables and fertility, characterised by the proximity to fertility. Examples are the use of contraceptives or infecundity in a population (Bongaarts & Potter, 1983:1). Marriage patterns, contraceptive use and use of induced abortions are the “ways in which a population can control its fertility below the levels implied by the natural marital fertility rates” (Bongaarts & Potter, 1983:52). One useful grouping of the factors influencing fertility divides the determinants into three components (See Figure 4) and provides a widely used overview of the demographic theory. The first group is the awareness of the choice controlling fertility and is described in 1973 as ‘the calculus of conscious choice’ by demographer Ansley Coale (Guilmoto, 2009). The second is the desire to choose to have children, and this is correlated with level of education, degree of urbanisation, child mortality rates and women’s status. The third component is the ability to choose, i.e. having the means to do so, and this component consists of for example fecundity, contraceptive use and their effectiveness. This grouping thus combines proximate factors (the ability component) and socioeconomic factors and social conditions (the willingness and readiness components). This conceptualisation

thus

combines major theoretical from

contributions within

Figure 4. Grouping of preconditions for fertility decline  Readiness: fertility limitation is within the “calculus of conscious choice”  Willingness: reasons to limit fertility o E.g.: employment possibilities, child mortality  Ability: availability of family planning methods o E.g.: fecundity, contraceptive use (Adapted from: Guilmoto, 2009; Lesthaeghe Vanderhoeft, 2001; Bongaarts & Potter, 1983)

&

demo-

graphic literature. There are debates over the relative importance of each factor. One hypothesis worth mentioning here, since I discuss it in relation to my empirical material is that of child survival. Within this hypothesis, emphasis is put on the importance of child survival, stating that as child mortality declines, fertility follows (Lloyd & Ivanov, 1988). Moreover, religion and culture play important roles for fertility as do a number of factors. No one factor can be said to have the single most importance, hence a conceptualisation that combines a range of factors influencing fertility. The conceptualisation provides a widely used handle by which to understand fertility, and the three components can be used to analyse what determines fertility in a given 38

Theoretical framework setting. However, a factor that lacks an explicit role is the political situation in the setting at hand. As presented in the review of the literature of fertility in Palestine, it is precisely the shortcomings of both socioeconomic variables and proximate determinants in explaining fertility rates that renders a concept of political fertility necessary. The hypotheses presented above all assume a level of free choice and a fundamental association of development with a desire for decline in population growth. Yet not all women are able to make a free choice, and political considerations that go against wanting decline in fertility will play a major role in some settings. In addition, the model builds on a positivistic understanding of causal process and preconditions and as I look to an aspect of fertility with a more unstable ontology by which I perceive fertility as socially constructed and contextual I attempt to keep this ontological difference in mind throughout the use of this theoretical framework. 4.2

Power, biopolitics and discourse

The theoretical tools that serves as a way of orientation towards the empirical material and of opening up the perceptions of fertility are political power, biopolitics and discourse, all presented below. Political power is exercised through fighting for the right to define what is true, possible and wanted (Vallgårda, 2007:40). The understanding of power employed in this thesis takes as a reference the definition by social scientist and philosopher Michel Foucault. Power is therefore not understood as negative or destructive enforcement, but rather as a complex and productive construction exercised through relations (Foucault, 1994:97-102). Power is not something one can possess or take from others, as power is located in social structures (Foucault, 1994:97-102). There are things that can be said and thought, just as there are things that cannot. Such an understanding enables an approach to the field in which the attention paid to what is not being said or done sharpens the analysis towards what is taken for granted. Political problems are thus not just something that are there, rather they are created, recreated and emerge from a ongoing processes of definition (Vallgårda, 2007:42). With this understanding of power, a policy is here seen as an example of performing politics, and thus implies power. If a policy can exert power, then the non-existence of a policy also exerts power. An important aspect of the Foucaldian notion of power is that power both disciplines the individual and regulates the population. Power hereby shapes the individuals and their actions, thus creating and controlling other people’s 39

Beyond Numbers: Political Fertility in Palestine possibilities of actions (Heede, 2002:43). This is especially relevant for the understanding of biopolitics. Foucault is credited with being the father of this term biopolitics and his interpretation of the term has been used, redeveloped and critiqued in different ways (Lemke, 2009). As for its use in this thesis, I am inspired by and follow the Anglo-Saxon interpretations and use of the term by social scientist Thomas Lemke. The concept of biopolitics refers to the emergence of a new form of government and rationality during the 18th century in European states that were facing challenges from their populations’ health, birth rates and reproduction. At the same time emerged new forms of techniques of submission of the body and control of the population (Foucault, 1994:144). With these developments emerged a new form of power, that of biopower. The prior form of power that was able to “let die or keep alive, is replaced by a power to let live or send to death” (own translation) (Foucault, 1994:142), hence expanding the scope and aim of this new biopower’s reach. Foucault’s conceptualisation of the term biopolitic is based on an understanding of life as separated from the actual bearers, not to be understood as individual experiences but at a population level and is understood as one of the two technologies of biopower. The development of this concept is linked to the use by states of scientific methods such as epidemiology and demography which analyse life on a population level in order to ‘rule’ or govern individuals and collectives (Lemke, 2009). Hence, with these scientific methods it became the size and the quality of the population that came into play through regulation of the population and the discipline of individuals (Lindgren, 2000). Biopolitics is, according to Foucault, the regulating control of the biological process such as reproduction and births (Foucault, 1994:143). Family planning services can in this view be seen as a way for governments or organisations to manage the reproductive behaviour and the fertility of populations, and is therefore central to biopolitics. Politics and power over what is biological is central to this term. Another concept that serves as a perspective through which to understand my empirical material is discourse. Similar to biopolitics, this term is often ascribed to Foucault. In order for the term to be useful for my analysis I am inspired by the reading and further development of political theorists Ernesto Laclau & Chantal Mouffe on discursive battles, a more specific term rather than general discussions of discourse by Foucault. According to the reading of Laclau & Mouffe by Torfing, a discourse is a “differential ensemble of signifying sequences in which meaning is constantly renegotiated” (1999:85) or to put it another way, as trying to narrow down or settle the meanings 40

Theoretical framework of different elements when this is never fully accomplishable (Jørgensen & Phillips, 1999:35-8). Language then becomes a social phenomenon, since it is through negotiation and conflict in a social space that meaning is ascribed and challenged (Jørgensen & Phillips, 1999:35). And in the discourse theory of Laclau & Mouffe, they describe the processes of this constant negotiation and instability of ascribed meanings. Meaning is sought to be ascribed to signs in attempts to fix an unambiguous meaning to this sign, reducing the ambiguity. Yet there will always be other possible meanings that can shape the sign, and this potentiality constantly threatens stability (Jørgensen & Phillips, 1999:39). In the understanding of discourse by Laclau & Mouffe, changes in the ascription of meaning are political actions. Political should here be understood as constructing the social in certain ways, while simultaneously excluding other ways. By temporarily attaching meaning to a notion, dominant discourses are either reproduced or changed, and hereby society is constructed in one way and not in another (Jørgensen & Phillips, 1999:47). This section does not serve as a comprehensive review of the theory of power, biopolitics and discourse, however it serves to sharpen my perspective towards a critical view on what is governed and disciplined as well as what is taken for granted. This is to set the scene for the underlying assumptions of the analytical work that follows after this chapter. They will not be used in the analytical work in the same way as they would in a strict discourse analysis, for example, but rather as a ‘can-opener’ to understand the empirical material. These concepts of Foucault are based on extensive studies of the historical development of the modern state in Europe, and thus have roots in another culture and historical period than my empirical material. However, I believe that these concepts are useful for my analysis and can be transferred to a Palestinian context, partly since I strive to not force the theory onto the empirical material, and partly since the discourses of international actors influence the family planning discourse and politics in the West Bank to extent that they do. My inspiration originates with the Rhoda Ann Kanaaneh, who uses the theoretical concepts of Foucault to analyse family planning for Palestinians in Israel. I have now presented my main theoretical concepts and inspiration. The outline of the demographic concepts serves as the theoretical foundation of my initial approach to the field and my interest in understanding political fertility. Moreover, the theoretical concepts of power, biopolitics and discourse provide me with handles with 41

Beyond Numbers: Political Fertility in Palestine which I can approach the empirical material. This orientation towards the research process enables me to see aspects of power being exercised as well as to become aware of ways in which meanings are negotiated. Thus I understand a notion as fertility as being constructed, dynamic and fought about, and perceptions of fertility can therefore also be deconstructed and understood differently. This is an empirically governed study and I have used the concepts of power, biopolitics and discourse in a constant confrontation with the empirical material and hence they serve as ways to explain what emerged from this empirical material.

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Empirical Evidence and Analysis

5

Empirical Evidence and Analysis

My main finding from the analysis of the empirical evidence is that there are clear political aspects in the perceptions of fertility amongst mothers, health providers and policy planners, and most importantly, that fertility is more than merely numbers. In the following three chapters I unfold the analysis and argue for this concluding statement by describing and discussing three themes that have emerged from my empirical material collected during fieldwork: Having Children, Being Palestinian, Beyond Numbers. The analytical structure is presented in Figure 5. The first theme revolves around the main part of fertility: deciding to have children. The second theme contextualises fertility to the reality of Palestinians. The third and final theme gathers together analytical points made in the previous two chapters. It revolves around the concept of fertility being about more than about the number of children – a major analytical conclusion of this thesis.

FERTILITY IN PALESTINE I) Having Children: Making the Decision

II) Being Palestinian: Palestinian Positioning

III) Having Children in Palestine: Beyond Numbers Figure 5. Structure of the analytical chapters

The three analytical chapters are structured as follows: in the first section of each chapter I present the perspectives from the empirical material of the interviews with mothers. In the second section I present the observations of and interviews with the policy planners, health care providers and the clinical practice. This division of the empirical material is based on an understanding of the mothers as the recipients of family planning services and policy as opposed to the clinic, the health providers and the policy planners being the senders. Finally, I analyse and triangulate the empirical material and apply theoretical concepts and findings from other studies to open up the analysis. 43

Beyond Numbers: Political Fertility in Palestine

6

I) Having Children: Making the Decision

The first analytical question revolves around fertility’s most central decision: to have children. My inquiry is motivated by the naturalness of motherhood seen in the empirical material. I shed light on what shapes decisions to have children from the point of view of mothers living in Kalandia camp, from the clinical daily life in conducting health care services related to this decision to have or not have children as well as from the point of view of policy planners. Such decisions are actively constructed by the woman as well as shaped by decisions taken outside of the private sphere, since the policy sphere and the services provided play a role in shaping fertility decisions. Thus this theme triangulates perspectives from all my empirical material. This theme takes us far: we will go into the access to the means of being in control of the decision to have children; reasons for having children for the nation and for the kin; and the political aspects of fertility in terms of biopolitics. All of these dimensions will be discussed in the third section of this chapter. 6.1

The point of view of mothers

The points of view of the mothers in Kalandia camp on the theme of having children and decision-making on fertility is presented in this section. 6.1.1

The setting in which the mothers live

Before describing what was said by the mothers, I will describe the setting of their lives in Kalandia camp. It is not the sight of a “classical” tent refugee camp that greets one when entering Kalandia camp. Most buildings are closely aligned two- or three-story concrete residential houses. The streets resemble a maze, and scattered around are small kiosks and coffee bars. A few vines and olive trees insist on surviving despite the lack of sunlight and room to grow. Graffiti in the colours of the Palestinian flag light up the bare walls of most houses. The camp resembles a residential suburb of Ramallah and from the camp it takes 10 minutes by car to the city centre of Ramallah. Kalandia in many ways seems to be part of Ramallah, and not a separate refugee camp. In Ramallah’s centre, I recognised several patients from the clinic, underlining that Kalandia is an urban area and a part of Ramallah. There are not many people around in the streets of Kalandia camp during the daytime, mostly just a few cars and motorcycles, and in the afternoon children, either playing or walking home from school. In my interviews with the mothers, several told me that they do 44

I) Having Children: Making the Decision not allow their children to play in the streets of the camp as they worry too much about them. The streets are narrow and winding and a car could come around the corner at any time. Moreover, they tell me that a young student from the camp was shot dead by Israeli soldiers a month earlier at the end of August that same year. They therefore also fear unrest, soldiers, and arrests. This is the setting of the lives of the refugee mothers that became my informants. 6.1.2 What mothers say: it is natural to have children I asked my informants why they had chosen to have their children, and the most prominent reaction to this enquiry was great surprise from the mothers. Wanting children and having children is seen as the most natural thing, a fundamental part of life, so why was I questioning the reasons to have children? It is perceived as the natural circle of life and the plight of the human race, or as one mother puts it: “because [having children] is what life [is] about” (F169)21. It is Gods will and you should be thankful to God for giving you your children. These are the answers I got to a broad and abstract question. Turning the question away from their children towards a general discussion of the value of children turned out to be easier for the informants to answer. The mothers now mentioned a wider array of reasons for having children, although these remained centred around the norm of having children. Mothers would talk of a longing for babies and a passion for having children as what drove them to have (more) children. Others would also emphasise a spiritual, religious factor of wanting to have children, as this is prescribed in Islam and as children is needed for the survival of the human race. Children were also seen as a means of security in old age and as an investment in the future, not just in financial terms, but even more prominently in the material, in terms of the Palestinian state. Children are seen as the hope of the Palestinian state and the national strength, as in the words of a mother I interviewed: “children are [the] strength of the family and a force to face the world who in its majority [is] against us. [...]Palestinian children are [the] strength in front of the world” (D140). Hereby, this mother couples having children with both the fight for Palestine and the stronghold of the Palestinian family. Others also mentioned having children in order to keep the family name and the status of a large family. No one in the empirical material questions whether or not to have children. The only argument men-

I refer to my empirical material by reference to which interview the quote stems from followed by the line number of the matching transcription. 21

45

Beyond Numbers: Political Fertility in Palestine tioned for having fewer children is not to have more children than one is able to support financially. 6.1.3 Knowledge and utilisation of family planning methods Informed by the demographic literature on availability, I asked questions about what the mothers thought of family planning methods and the family planning services in the UNRWA clinic. I was surprised that the mothers were not embarrassed to talk about family planning. Most mothers would talk openly to me about their use of contraceptives, in front of their children and in-laws and us as strangers. I met scepticism towards modern methods of family planning from only one mother, who due to perceptions of side-effects would not use any modern family planning methods. The young couple I spoke to complained that the wife did not receive adequate explanation from the nurse at the clinic, as she was merely handed some pamphlets. The majority of informants told me that they were happy with the service of the UNRWA clinic and of the methods provided at the clinic. These mothers value that the health providers do not interfere with the decision to use family planning, since the health providers merely inform them of the available choices and associated sideeffects, and then leave the decision up to the woman. 6.1.4 Infertility My assumption when arriving in the field was that fertility in Palestine had to do with having many children. I had no intention to look at infertility or the fecundity of Palestinians, yet infertility emerged from the field as an important category. In half of the interviews with mothers, infertility appeared spontaneously in the conversation on the initiative of the mother. It turned out that the subject of fertility for the mothers of Kalandia was about more than deciding when to have children. As the niece of one of my informants put it: ”The point is [...] not that we want to control the births…many can’t control it.” (B224), referring to her friends unable to have children due to infertility. The decision to have children is not about controlling conception, but about being able to become pregnant. Since infertility emerged so overwhelmingly in my empirical material, I will now present in detail an illuminating case story of an informant, a mother of one in vitro fertilisation (IVF)-child. Her story tells the sad and unfortunate story of a woman in Kalandia, yet it also gives an insight into social expectations of having children; health seeking behaviour of people living in Kalandia camp and conflict-related aspects of access to health care; and her perceptions of political pri-

46

I) Having Children: Making the Decision oritisation of donors on infertility treatment. I now present her story, and in the third section of this chapter I discuss the implications. 6.1.4.1

An illuminating case: a desperately infertile woman

In the clinic earlier that day I had found her file among the previous day’s patients, and with the help of one of the clinical nurses I set up the interview. Over the telephone, she had told us she only has one child and asked if I was still interested. She seemed uncomfortable through parts of the interview, talked a lot off subject and became tearful a few times during the time we visited her. Nevertheless, she insisted on telling her story: She is a 37-year-old refugee woman, mother of one 10-year-old son, living with her husband and determined to have another child. She suffers from secondary infertility22 and went to extreme measures to give birth to her one child. Ten years went by from when she was first married until she had her son, and she has been through 5 IVF treatments, besides the one that resulted in the birth of her son. She and her husband have spent a huge amount of money on different treatments: they sold their gold in order to pay for medication and treatments, obtained money from relatives, and approximately one-third of the husband’s income goes towards medication. Her focus is on pills, medication and medical examinations. She answers in short sentences throughout most of the interview, but can talk for longer about medical procedures and visits to hospitals. She sees infertility as a biological malfunction in both her and her husband, and infertility in his family is well-known; “all four of them …the brothers… have weak sperms” (E350), she explains. In line with other mothers I talked to in Kalandia, she links suffering from varicose veins to their infertility. She believes that an operation her husband had for varicose veins is related to their infertility, and tells me how it runs in the family: “[My] brother-in-law [...] also had the varicose veins operation like my husband…his wife got pregnant directly after marriage…and [...] she is now pregnant with the second baby.” (E360). She seems to believe that the operations her husband and her brother-in-law have gone through have helped their fecundity. She is going through all this for her son, she says. She wants him to have a brother or a sister. He is experiencing being different from other children and wishes for a sibling. The mother tells me that at her son’s school the questions in English classes are WHO differentiates between two forms of infertility: “Primary infertility is infertility in a couple who have never had a child. Secondary infertility is failure to conceive following a previous pregnancy.” (WHO, 2012). 22

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Beyond Numbers: Political Fertility in Palestine based on examples with sisters and brothers, and her son has to answer sentences about having siblings in class: “[T]hese question bother him and he comes home angry” (E285). This story gives us an insight into the social world of this young boy, as he feels different and therefore wishes for a sibling. My informant also states that she herself longs for another child: “it is me who want another baby…need to fill my time and have another child in the house” (E321). She feels there is a social expectation to have more than one child, which is why she is so desperately trying to have another child: “honestly…I feel edgy and want to cry…it is very hard in our society to have only one baby…you can notice that in the [A]rab world.” (E306). She does not know of many women who have no or few children, and this affects her wellbeing. The biological effects, the financial burden and social expectations all seem to take their toll on her: “tell you the truth…I feel depression …my psychological health…I really feel uneasy when I see young babies…I love them” (E396). She feels that the effort and health consequences of the courses of IVF treatment and the constant medication are strenuous, yet she continues with the treatment and suffers mentally. Her longing for another baby is stronger than any of these other circumstances. With a smile on her lips she tells me that they have been to 15 different doctors over the last 20 years: “whenever we hear about a better doctor we go” (E85). My informant goes to the UNRWA clinic for minor things, she tells me, as the major medications for difficult cases are not available in the clinic. She holds a Jerusalem ID which means she is entitled to health care from the Israeli medical health insurance. She travels to Israeli hospitals in Jerusalem for medical investigations and treatment. Her husband was born in Kalandia and therefore holds a Palestinian ID, excluding him from the Israeli services free of charge. My informant is very aware of the conflict’s discriminatory implications with regards to access to health services. She wonders why UNRWA are not prioritising paying for this health problem of infertility that she sees as highly important, widespread and with treatment options out of the financial reach of many Palestinians, while the Israeli health insurance has chosen to finance up to three IVF treatments for those entitled to Israeli health care. She told me: “They [UNRWA] said that they don’t help with these things…although these things are really expensive and important…we talk about Israel…they finance 3 operations like the one I need for each couple who can’t have children…in order to have 3 children.” (E380).

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I) Having Children: Making the Decision For her, the politics of the donors and the authorities are very much of interest. Her first and second IVF treatments were paid for by the PNA, the first in 2001. Here I leave the empirical case of the women whose desperation shows us the power of the social expectations of Palestinians to have children. I later discuss how her story fits with other parts of my material, and how it exemplifies the presence of political fertility amongst mothers in Kalandia. The empirical evidence from all the mothers raises a wide range of analytical perspectives, which I will go into alongside the perspectives of the policy planners and the clinical practice after these have been presented. 6.2

The point of view of policy planners and health providers

I now proceed to present the empirical material on the decision to have children as it emerged from the data from the health clinic and the policy planners. 6.2.1 The setting of providing family planning services First I will describe the setting in which family planning services are provided. The UNRWA clinic in Kalandia is situated at the entry to the camp. The clinic is a 2storey building (see Figure 3) with a waiting room on each floor, examination rooms used by the clinic nurses and doctors, a clerk office, a laboratory, a dentist, a psychosocial counsellor’s room, a mother and child health (MCH) room, an antenatal care (ANC) room where all visits concerning reproductive health take place and a pharmacy. The clinic serves approximately 20,000 patients, many of whom live outside the camp either in Ramallah, Jerusalem or nearby villages. Consultations, prescribed medicine and contraceptives are provided free of charge and are readily available through the clinic pharmacy. Patient files are organised by a main Family File registered in the head of the family’s name with a refugee ID-number. The wife and children belong to the same file and there is room for up to 12 children on one file. They have 230 registered pregnant women and 850 women registered for family planning. Family planning services consist of counselling and education of the woman individually. The nurse sits behind the desk in the ANC room and gives information about use, effects and side-effects of family planning methods. The women come for advice on family planning, to pick up a handful of condoms or a new sachet of pills, or to change method due to side-effects. The contraceptive methods available in the clinic are male condoms, IUD (copper-containing IUD), ‘the pill’ (combined oral 49

Beyond Numbers: Political Fertility in Palestine contraceptives and progestogen-only pills for breastfeeding women), injectables (hormones injected intramuscularly every three months) and the diaphragm (called the “pessa” by the staff). The health staff told me that the patients prefers IUDs. From the clinic’s side there is no involvement of men in the use of family planning, as the staff perceive this as too difficult due to lack of interest from the men. As opposed to the practice of the MoH, UNRWA has introduced emergency contraception, but frustrated staff told me these had not yet been delivered to the clinic. While I was there I noticed women asking for condoms, but there were none left in the cupboard, as the clinic had run out. Inside the ANC room there are five filing cabinets along the wall, with large labels on them stating either “Condom”, “Pills, Inj + Pessa”, “IUD”, “PCC” (pre-conception care), “AN” (antenatal), “PN” (post-natal) in English (See Figure 6). These cabinets and their labels can easily be seen from the waiting area. The files for the female patients’ reproductive health are separate from the Family File, and these Maternal Health Files are filed by the woman’s reproductive status. According to this filing system, a woman can be either pre-conceptive, pregnant or a user of a family planning method. The files in the latter category are sorted by which contraceptive the woman is using. The labels on the filing cabinets thus match all these categories. When a woman comes to the clinic, they have to get their file in order to be placed in the queue to see a nurse or a doctor. Figure 6. The filing cabinets of the antenatal care room of the UNRWA clinic in Kalandia camp.

This means that women barge into These contain the Maternal Health Records of the clinic’s patients. Photo taken 24th of September 2012, the ANC room, sometimes during a LNH consultation, and state their reproductive status or which contraceptives she uses in front of other patients, a certain 50

I) Having Children: Making the Decision number of health providers and those listening in the waiting area. The nurse will then find her file in the appropriate cabinet whose labels state that this woman uses for example condoms. This lack of audio-visual privacy did not seem to worry either the women or the health staff. I asked the staff about privacy and they responded that most of their patients know each other and do not mind. On the other hand, the providers also stated that it is the right of the patient for the health provider to ensure their privacy, and especially in the ANC room the door would often be locked. During a consultation with a woman who wanted her IUD checked, I was asked by the nurse to move to the other side of the curtain to the examination couch while the nurse at the same time locked the door of the ANC room, all to ensure the privacy of the patient before starting the gynaecological examination. Some medical encounters are seen as sensitive requiring privacy. Along those lines, the only product that is not handed out over the desk of the pharmacy is condoms. These are handed out in the ANC room and upon asking why it is organised in this manner, I received the answer: “We cannot give women condoms in front of everyone” (OBS). To my cultural understanding of privacy there seems to be a lack of privacy in the filing system, yet not necessarily in other practices in the clinic. 6.2.2 Infertility was not on the policy agenda Contrary to my interviews with mothers, infertility did not appear spontaneously in my interviews with policy planners or health professionals in the UNRWA clinic. However I chose to bring it up in a few interviews after it emerged in my interviews with mothers. One afternoon in the medical examining room I told the Senior Medical Officer about the latest Palestinian Family Health Survey from the PCBS, released a few days earlier. I told him that according to the survey 8% of Palestinian women are infertile23, and he was very surprised by this number. He said that these patients know the UNRWA clinic cannot treat them, and instead the patients go directly to specialists. He thought the number was 3-4%, so the scope of the problem took him by surprise. Infertility is not a health issue seen as through the participant observations at the UNRWA clinic. According to my informant in the MoH, the MoH can no longer afford to support infertility treatments as they could previously, and in her experience donors do not According to the survey 8% of married women in the reproductive age (15-24 years) reported infertility, out of which 4.8% were suffering from primary infertility and 3.6% of secondary infertility (PCBS, 2011:149). 23

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Beyond Numbers: Political Fertility in Palestine wish to support infertility programs as they prioritise family planning higher. The PNA had to restrict access to such treatment due to financial considerations: “it is very expensive and the Palestinian Authority [...] didn’t have money [...]. Money for our salary they didn’t have” (MoH495), my informant said jokingly. Instead the MoH is now reliant upon donor funding from external parties: “[T]he mandate of the donors [is] family planning and not infertility. [A]ll donors [...] prefer family planning. […] If you ask any donors ‘I want to work on this issue’ they say it is very expensive and it is not our mandate. This is the answer all the time.” (MoH487, ‘quotation’ added by LNH). The funding is tied to the interests of external organisations and not the PNA, showing us how closely the PNA and UNRWA have to work together to coordinate and how mutually dependent and influential they are. Family planning programs of the MoH and of UNRWA thus does not entail infertility treatment. The informant from UNFPA did not mention infertility with at all when presenting the reproductive health programs of UNFPA in the West Bank. So, the empirical evidence from the observations and interviews with those behind family planning services shows us that such services are in place and being used, however there is some lack of privacy. We also see that family planning focuses on contraceptives and not infertility treatment. 6.3

Triangulation: deciding fertility

Gathering the statements of the mothers and the policy planners as well as the observations from the clinic, and triangulating these with theoretical concepts of demography and biopolitics, I will now go into the analysis of my research question of the decision to have children in Kalandia. Having children is what makes up fertility and decision-making is shaped amongst couples, families, in society and in policies. With my empirical material I can shed light on the woman’s side of the decisions and perceptions about what is of importance for shaping fertility, as well as on how the practices of the clinic and family planning policies shapes fertility. I am aware of the large influence (and presumably dominating role) in the decision-making of husbands and mother-in-laws, yet with my methodological choice of informants I am not able to shed light on their roles. 52

I) Having Children: Making the Decision Instead, I can triangulate perceptions of mothers, health providers, clinical practice and a policy sphere. I have presented a wide range of aspects in the empirical material, and to analyse these I approach the material from two rather different angles. Firstly, I will analyse the social importance of having Palestinian children in relation to the factors that are said in demographic terms to determine fertility decisions. Secondly, I will analyse the biopolitical aspects of the empirical material. 6.3.1 Political perspectives’ contribution to demographic knowledge In the following I will argue that it is necessary to include a political perspective to the understanding of what is at stake for fertility decisions in Palestine. If fertility is conceived merely by quantifiable determinants as it is presented in most demographic literature, the influence of for example Palestinian mothers’ considerations of whether to have another martyr for the sake of the nation will be missed. I have found evidence that brings nuances to what is at stake for fertility in Palestine, and my methodological approach and epistemological point of departure allows insights into what lies in the construction of the perceptions of having children, thereby enriching the knowledge gained from the studies of trends of quantifiable variables and fertility rates in Palestine. In this section I thus relate the empirical evidence to the factors influencing fertility presented in the demographic literature. I will show that political aspects constantly play into the influential factors that can be recognised from demography. As presented in Chapter 4, the various determinants of fertility can be grouped into three components of readiness, willingness, and ability. The choice of wording that lies at the core of this approach to the study of fertility – of a calculus of conscious choice of having children and the ability to make such a choice – assumes a rational individual able to make such choices freely. Yet in Palestine hardly any individual woman, and none of those in my empirical material, takes such decisions on their own due to her own private desire. Such things are negotiated constantly within a collective of either the family or the nation (Kanaaneh, 2002; Taraki, 2006). It is therefore crucial to challenge the factors put forward by classical demography in order to grasp the nuances provided by my empirical material. For this reason, I relate the way of understanding fertility as presented above with my empirical material. I start with the ability components in relation to family planning services.

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Beyond Numbers: Political Fertility in Palestine 6.3.1.1

Deciding fertility: access to family planning services

In accordance with the recommendations of the WHO (see WHO, 2011), the refugee population of Kalandia camp has access to effective contraceptives and information about family planning free-of-charge and with a policy statement that ensures this access. The UNRWA clinic in Kalandia provides information brochures and counselling, though in practice it is rushed at times and not adequate for all, as the young couple complains. On paper there is access to methods of family planning, while in practice it happens that women leave the clinic empty-handed. The clinic runs out of condoms and has not yet received the emergency contraceptive pill. The services are perceived by the majority of mothers as culturally acceptable and effective, and the utilisation of family planning is seen to be high24. Shopping around for health professionals is commonly observed in my empirical material and is seen especially in the case of the woman seeking infertility treatment who goes to a new provider as soon as she hears of one. Health seeking behaviour is determined by the health care options that exist (Hardon et al., 2001:35), and in the West Bank a maze of health services are provided through MoH, UNRWA, NGOs and a wealth of private (Mataria et al., 2009), and the wide range of providers enhances the theoretical availability of family planning services. There are no infertility services available at the clinic, and from my observations it is clear that family planning at the clinic is considered to be contraceptives, and not infertility treatment as the definition of family planning by the WHO (WHO, 2011) states. The importance and significance of infertility to policy planners and health providers does not correspond to the perceptions of the mothers of Kalandia refugee population that I spoke to. There is clearly a discrepancy between the demand for services and the supply, thereby reducing infertile women’s options of choice to have children. The lack of focus on infertility from the clinic’s and policy planners’ side could be an indication of a health political environment in which encouragement to have more children is frowned upon. Navigating in a field where foreign donors fund substantial parts of the health services makes encouragement to have children a delicate matter. Prioritisation of funds is always highly political, and the prioritisation of contraceptives over infertility treatment had made at least one mother wonder about the agenda at the policy level,

Due to the collection method for data in UNRWA, it is not possible to calculate the coverage of family planning methods at camp-level. The prevalence of modern contraceptives among refugee women of reproductive age utilizing UNRWA MCH services in all of the West Bank is 59.1% (UNRWA, 2011b). 24

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I) Having Children: Making the Decision making the case of infertility in my empirical material a relevant example of ensuring access to family planning services in Palestine being seen to be highly political. 6.3.1.2

Deciding fertility: the desire to have children

The willingness to have children as a component of fertility determinants provides a handle to analyse the desire and naturalness of having children. When applying this component to my empirical material, micro-level aspects that emerge most clearly. As we see from the empirical evidence daily, life in Kalandia camp is highly influenced by the political situation and the conflict. For example, the mothers fear for their son’s lives when they play in the streets of the camp. One aspect of this willingness component is that of child mortality. In child survival theory, the desire to have children declines with improvements in child survival, and emphasis is put on the role of under-5 mortality rate (U5MR). The child mortality (U5MR) in Palestine has declined (Rahim et al., 2009), however the fertility rates are relatively high, posing questions about whether the theory fits the Palestinian case. Perhaps what influences fertility desire is rather the fear of losing a teenage son due to unrest in the streets, or a young adult son due to imprisonment (as we see in the next chapter). Adolescent mortality and imprisonment is possibly more prominent in determining fertility in Palestine than U5MR. A contextualisation of such factors is hence necessary. In the following, I argue for the need to include the role of the nation and kin when understanding fertility in Palestine. As in many societies, motherhood and having children in my material is seen as the natural progression of a woman’s life. This is found in the reaction of surprise I got from the women when asking why they had their children, showing the naturalness of such a desire to become a mother. Also, the case of the woman suffering from secondary infertility paints the picture of a social expectation of motherhood. Her role as a housewife is expected to be built around raising children, yet as she has only one child to raise, her life becomes about having children instead. Infertility was perceived to be more serious and devastating for the women than having too many children. Fertility was for these women not about family planning, as in controlling when and how many children, but about the capacity to have the children they want. Having children is the norm, leaving not having children as the abnormal, or due to

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Beyond Numbers: Political Fertility in Palestine something involuntary. I was told that the reaction to having ‘too few’25 children would be “ya haram”, which is Arabic for ‘what a shame’. All this shows the importance of fertility, the desire for children and the presence of a social expectation of motherhood. The nation comes up repeatedly during conversations, and the nation plays a large role in the everyday life of my informants. Walking alongside nationalistic graffiti in the streets keeps the nation in people’s minds. The importance of the conflict and the nation in the desire to have children is seen in the quote presented earlier: “Palestinian children are strength in front of the world” (D142). Uttering these words hence couples children with fighting, in this case for a Palestinian nation. In this interview I asked her 9 year old son about his future aspirations: “I want to [be a] martyr when I become 20” (D110), was his answer. Also, he at the age of nine knows of the perceptions of the children and the youth in their role for the nation. Having children made my informants talk about the past and the future. It both awakened thoughts about their own childhood and how this should shape their children’s childhood, but for those that talked about the political meaning of having children, the future was more important. They saw Palestinian children as hope for the nation. The hope might not be large, but while mothers do not see change likely to happen within their lifetime, their children become an extension of their lifetime. Within the lifetime of their children, the situation for Palestinians might change. In this way, having children creates hope for the future of the nation. Hence, political and nationalistic aspirations are presented by some mothers alongside and intertwined with their reasons for having children. The importance of kinship also emerged in the material as a prominent factor in forming the desire to have children. My informants were not having children merely for their own sake, as much as it was about giving their son or daughter a sibling, or following the advice of their mother-in-law. Having children entails the creation of a family, albeit families take many shapes. Kinship has historically been at the centre of ethnographic research (Tjørnhøj-Thomsen, 2004:140), and it is therefore not surprising that in the empirical material family and kin played a large role. The Palestinian family is characterised by Palestinian Professors Sharif Kanaana and Ibrahim Mu-

25

8).

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My third research question deals with exactly the perceptions on numbers of children (see Chapter

I) Having Children: Making the Decision hawi as being extended, patrilineal and patrilocal (Kanaana & Muhawi, 1989:13). This means that when a woman marries, she moves into the house of her husband’s father (Buch, 2010:137). In Palestine, this will often mean the new conjugal family moving into a separate unit situated in the same building as the extended family, which is often of three generations (Kanaana & Muhawi, 1989). This practice and the importance of the extended family and the patrilocal living arrangement are also seen in my material. Several of my informants told me of their relatives living upstairs or next door, or they dropped in and out during the interviews. The young couple I interviewed were living in the same building as the husband’s brothers. He explained: “[W]hen I decided to get married I built this house over my parent’s. When my brother after me wanted to marry, he built his house on the top of mine, and so on” (C53). By house he is referring to their apartment in a large concrete building quite far into the camp. The family calls that area of the camp by the name of the village their grandfathers came from in 1948, in what is now Israel. The heritage along the patrilineal lines carries great importance for family structure and social relations within society. These conditions emphasise the importance of having children in order to secure the continuation of the kin. My informant in the MoH told me that ‘iswah’ is an explanatory factor for wanting children in Palestine. She explained ‘iswah’ as: “[A woman] wants many children around her […], to support her, to say to her neighbor that I have 5 boys, 10 boys.” (MoH526). By Muhawi and Kanaana, the term26 is explained as the source of the strength that the unity of the family gives (Kanaana & Muhawi, 1989:17). A large family that ensures unity and solidarity will stand strong against any challenges that arise, and living in a conflict, this kind of security becomes crucial. The strong family is seen as “the basis for their economic existence and social identity” (Kanaana & Muhawi, 1989:17), thereby showing us the importance of kin to Palestinians’ lives. Having many children (and preferably sons) secures the future both financially and socially. For Palestinians this influences the desire to have children, especially boys, again rendering kinship an important factor to consider in Palestinian fertility. Understanding the patrilinear family structure and patrilocality of Palestinian families also helps us interpret the presence of son preference in the empirical material. An

In their transliteration, the term is spelled “izwe”, whereas in my transcriptions I spelled the term “iswah”, yet according to the two explanations the words have the same meaning. 26

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Beyond Numbers: Political Fertility in Palestine elderly mother I spoke to in her home, where she lives alone, repeatedly said “they left me no children to take care of me” (G202) about the Israeli soldiers that killed her one son, injured another son and imprisoned the last son. In addition to these three sons, she has two adult daughters, yet they are not mentioned in such statements. Both daughters have married and are thus moved out of the home of their mother. Even as the eldest daughter, who is present in the house, helps out with preparing food and cleaning while we interview the mother, her help does not count. The daughters are expected to take care of their own conjugal family as well as the family of their husband. These structures and social expectations mean that in order to have someone take care of you in old age, one must have sons. In addition to the factors commonly used to understand determinants of fertility, I have presented evidence for taking into consideration the factors of the conflict, nationalism and kinship when dealing with understanding the reality of fertility in Palestine. A political aspect is thus present in shaping the perceptions of the mothers I talked to in Kalandia to have children. 6.3.2 Biopolitics Since the upcoming of the modern state, decision to have children have become a crucial interplay between state and individual, this carrying the argument for including the policy level in this study. Decisions to have children are not merely taken on the sheets in the bedroom by a couple. On the contrary, society has a lot to say in shaping the decisions of couples, of families and of communities, through direct legal regulation as well as indirectly through welfare and health policy. Politics and power exercised in relation to aspects perceived as biological, such as fecundity or childbirth, is crucial to my empirical material. I will now show how biopolitics in Palestine is coupled to conflict politics, and how the governing of Palestinians forms two possible Palestinian ways of being: one which is acting according to expectation from within a health sphere and one which is acting according to a national objective of resistance towards the occupation. Family planning services are provided in order to ensure the biomedical health of women and children, while this form of biopolitics is equally conducted with nationalism at its core. But first I discuss where this decision to have children lies.

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I) Having Children: Making the Decision 6.3.2.1

Deciding fertility: private or public?

In my material there are several indications that the decision to have children is not perceived as a private matter. The influences of the extended family when the mother-in-law strongly advises the mother to have yet another child, or the pride I could glimpse when mothers told me that they are using family planning methods, just as the health professionals had told them to, are all indications of how a range of actors shape decisions about reproduction. The line between private and public is a gateway to understanding how such influences and actors are woven together. Privacy, in the understanding I bring with me, is different than privacy in the Palestinian context27. From a western public health and rights perspective, there seems to be an issue of lack of privacy in the clinic. It might not always be perceived as problematic by the patients or the health providers, yet it can result in sensitive medical issues not being presented at the clinic, yielding unwanted medical outcomes. Either way, it shows that what can be considered private in my view is in this context seen as also being a public matter. The picture is not without divergence and the distinction between private and public is a fine line to draw. Issues of fertility and contraception might still be sensitive and confidential, as seen when the distribution of condoms is done away from the majority of (male) patients. Yet reproduction and family planning are viewed as decisions that lie beyond the woman herself. The choice of filing in the Kalandia clinic without ensuring audio-visual privacy is a very clear display of how the public-private line is constructed in this situation. It can be interpreted as an understanding of reproduction as less private than in other contexts. The way in which the files can be sorted by reproductive status and not in a confidential, anonymous way shows that sharing information on reproductive status is not (always) perceived as problematic. In this biopolitical area the reproductive status of the individual is moved to the public sphere. The decision to have a child is not merely a private discussion within a couple, but is also debatable in wider arenas, and thus lies outside the intimate sphere. I have not been able to find this discussed in studies of Palestinian communities. However, Buch finds transparency to be more important than confidentiality as the repeated entrances of relatives throughout a conversation with an informant is done to monitor the social interaction out of a responsibility to know what is taking place (Buch, 2010:150). In personal communication with my cosupervisor, Buch, we agree that this can be transferred from the domestic sphere in her studies to the public sphere of a consultation in the clinic. Moreover, I experienced a similar incidence of intruding on privacy in relation to my previous internship in Ramallah, where I participated as an observer in psycho-social counseling interviews with newly released child ex-detainees. These are meetings assumed to be of a very sensitive and confidential nature (seen from a Western background), yet neither the interviewer nor the children saw a problem with my presence, but on the contrary encouraged it. 27

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Beyond Numbers: Political Fertility in Palestine 6.3.2.2 Politics on fertility In my empirical material, biopolitics can be viewed in the regulation of access to health care as a governing of biological creates while at the same time hinders possible actions and ways of being. The conflict in this way plays a crucial part in what services are accessible, dividing Palestinians up medically. Those with Jerusalem ID can pass through the check-points and seek health care in Palestinian hospitals in East Jerusalem or go to health professionals in West Jerusalem or other Israeli health facilities. These services are usually perceived to be of a high medical quality, with health professionals with a very high level of education from Israel, Europe or the USA. Medical services in the West Bank, for those without Jerusalem ID, are usually perceived as lower quality. In the case of the Palestinians, I thus find that the biopolitics conducted through this provision of services, is also highly correlated with the politics of conflict. Similarly, Bosman et al. finds that the governing of health is inextricably correlated to conflict politics (Bosmans et al., 2008). In addition, the understandings of the biological turn political in my empirical material. One such analytical point is very visible from the category on infertility found in my empirical material. Infertility is referred to as a health problem to do with ovulation, hormones, or quality of semen, or linked with having a medical problem such as varicose veins. The biological understanding of fertility, the fecundity of Palestinians, is perceived and constructed in relation to the conflict and the political situation of my informants: “This [hormonal problem] is one of the reasons why we have fewer children. Maybe the things that the Israelis [throw] in the air like tear gas…or the food we get from them [...] or maybe through the husbands who were imprisoned…” (B188). The biological components of infertility are thus linked to the conflict through the implications of the occupation such as the food being imported into the West Bank via Israel, the frequent tear gas thrown at the Kalandia checkpoint adjacent to the camp, as well as the treatment of Palestinian prisoners in Israeli prisons. In an article on Palestinian anti-colonial nationalism, political scientist Joseph Massad, quotes a communiqué from the Unified National Leadership of the Uprising (UNLU) during the first Intifada in 1989 in which miscarriages due to poison gas or teargas grenades are mentioned (Massad, 1995). This correlation of the conflict and the biological aspects of infertility is thus not merely seen in the household of a refugee family in Kalandia camp, as this also occurred in high-level political spheres during the first Intifada. The biological becomes political in a conflict where the ability to reproduce is linked to teargas, imprisonments and 60

I) Having Children: Making the Decision Israeli food. Fecundity is not perceived as a neutral factor at a constant level, on the contrary, it is perceived as a politically loaded factor, changing according to the surrounding political situation. Whilst having many children is understood to be political fertility, here it is infertility that is linked to the conflict, thus leaving not being able to have children as a mark of the conflict. The politics of the biological is thus again also the politics of the conflict, the two being intertwined. Biopolitics also helps to orient the analytical view towards what possible Palestinian actions are created by the governing of the biological. The health seeking behaviour of the Palestinians in my empirical material gives an insight into politically governed actions and options, thus applying the understanding of power presented earlier. The creation of possible actions for the population, possible ways of acting, and hence shaping and regulating the individual is to exercise power. Moreover, another example is that of the funding of infertility treatment. This is not an isolated case of fertility treatment being paid for by authorities, yet the prioritisation of funding is a clear example of regulating and controlling the reproduction and fertility of a population. The politics surrounding this biomedical area is of great concern to the people using such services. The agenda and political motives of the PNA, and the UN as well as the Israelis were eagerly questioned as an informant wondered why these different actors had the particular policy on infertility treatment that they have. This woman referred to the treatments as “presidential” (E51) and “on the expenses of Yasser Arafat” (E51) and thus personified the previous practice of the PNA to pay for infertile woman to have children. This personalisation of the leader of a nation paying for a treatment which results in a Palestinian child couples this child to the president and to the nation. It is common to talk of Palestinian leaders and land using parental metaphors (Massad, 1995). The linking of children to the Palestinian cause and nation is yet another instance in which the political world is linked to that of having children, emphasising the presence of political fertility amongst mothers in Kalandia. Hence as the private becomes public, the Palestinians decisions to have children gains political meaning, more than if such decisions are merely seen as the concern of the nuclear family. When the decisions to have children lies with the public, they have become a political entity that is governed and disciplined. By the provision of family planning a governing and regulation of the biological is seen. In exploring biopolitics in my empirical material, two possible ways of being are formed or as61

Beyond Numbers: Political Fertility in Palestine cribed from the provision of such services (both contraceptives and infertility treatment). The first is that of the biomedical Palestinian that use contraceptives and thus comply with expected health behaviour. The second is that of the national Palestinian that appears as the use of family planning is linked to the conflict as biopolitics become conflict politics. This national Palestinian appears as encouragement of having children is ascribed to the struggle through for example infertility treatment or family planning only as spacing, as we shall see in the third analytical chapter.

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II) Being Palestinian: Palestinian Positioning

7 II) Being Palestinian: Palestinian Positioning A recurring theme in the empirical data is the positioning of Palestinians. By positioning, I here refer to statements or actions in my material that create an identity by means of being opposed to or different from others. The second theme thus revolves around being Palestinian, and how this identity is constructed in different ways. Palestinians of the West Bank is positioned in relation to the Palestinians of the Gaza Strip and Palestinians in urban areas in relation to those living in rural areas. Both in Gaza and in rural areas fertility rates are higher than their counterpart I am told, and my informants explained these discrepancies to be caused by differences in the degree of development or the political situation, thus positioning the West Bank and urban areas as the most developed or the least affected of the political conflict. Another common positioning in my material is of Palestinians in relation to the West or Europe, and not surprisingly, the most common positioning in my empirical material is that of opposing Israel, the occupying power. So in this chapter I look further into the empirical data that revolves around positioning as Palestinians, in relation to Israel, the West or internally, and after a presentation of first the empirical evidence stemming from the mothers and then from the policy planners and health providers, I will relate the positioning to political fertility.

7.1

The point of view of mothers

Within the interviews with the mothers, the clearest positioning of Palestinians is that of Palestinians in relation to Israel and the occupation. Signifying how pressing historical political events are in the minds of Palestinians, dates referred to in the interviews were reckoned in relation to events such as the Intifadas or Israeli attacks, and while a mother I talked to did not remember the years of her children’s births, she remembered the exact date her son was killed, or martyred in her words, by Israeli military. My informants position Palestinians as a peaceful people in a situation that forces them to react. A woman told me of her sons that have been arrested and imprisoned by the Israeli military for having thrown stones at soldiers or for walking too close to the Separation Wall, and I asked her what she thinks of these acts. She said: “we are people who want peace, not war…but the circumstances sometimes make you do things that you [do 63

Beyond Numbers: Political Fertility in Palestine not] want to do…you sometimes have to go out…demonstrate…throw stones and [...] express your feelings…” (H52). I also talked to an older mother whose one son had been killed by Israeli soldiers, whose other son had been injured and permanently handicapped by the Israeli military, and whose third son is currently imprisoned in an Israeli prison. She was proud of her sons and showed me photos of them. She got her daughter to fetch portraits of the martyred son from the wall, while she pulled out an album of photos of the son in prison from her purse. In these photos he was holding a riffle. When talking about the loss of her one son and the fate of the others she became upset and sad, yet she phrased her loss as a sacrifice for the Palestinian cause. She also criticised the PNA for failing her, as she felt alone and without help or support from official side, even though her sons fought for Palestine. She positions the Palestinian youth as the real freedom fighters. A few days after this interview, a tent demonstration28 was put up across the street from the UNRWA health clinic (see Figure 7). The demonstration was a protest about the conditions of Palestinian prisoners in Israeli prisons with similar manifestations around the West Bank. Large posters were hung up around the two tents in Kalandia and I recognised the imprisoned son from the photos his mother showed me a few days earlier.

Figure 7. Tent demonstration over the Palestinian prisoners from Kalandia camp imprisoned in Israeli prisons. Tents and banners set up at the main entrance to Kalandia camp. Photo taken 12th of October 2011, LNH.

28

Tent demonstrations are a form of semi-permanent demonstration often seen in Ramallah.

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II) Being Palestinian: Palestinian Positioning This underlines how important a role prisoners play in the everyday positioning of Palestinians. An imprisoned son is not taboo, on the contrary his photo is hung to be celebrated in the camp. The youths have shown resistance towards the occupying power and their families have made sacrifices for the Palestinian cause and this is recognised and celebrated. Israel and Israeli soldiers are on the other hand positioned as a powerful, terrifying and unjust enemy. A woman whose sons were imprisoned told me: “[A] few days ago…the soldiers were in our neighbourhood…I was so frightened I kept reading verses from the Koran for preventing them coming inside the house… [...]. I was relaxed when they left the area and they were far from the house” (H148). The Israeli soldiers are positioned as a terrifying superior military power so frightening that they force you to stay inside, praying not to be faced with them personally. My material by no means shows a uniform way of showing resistance. My informants are in agreement on the need to show resistance, but not on which strategy is most appropriate. Neither is my interpreter. Choices of strategies are challenged, as is seen when Maysoon strongly tells off the nine year old son of an informant when he proclaims that his dream is to become a martyr when he turns 20. In fieldwork I experienced frustration over the superficiality of statements related to the conflict, the political situation or the occupation. Some statements had a touch to them of being standard phrases. In an interview with a mother with her six children all sitting with us in their living room, the woman was very brief in her answers. She replied in abrupt sentences, mostly just few words. She was open and smiling, yet she did not take the initiative to turn the interview into a conversation about what was on her mind. At one point I asked her about her dreams for her children, and as I tried to ask for additional details I brought up their roles as refugees. I asked her whether a wish to return29 was something she hopes for for her children. A little bewildered, she replied: “Inshallah…everybody wish[es] to go back to his original homeland before we die” (F92). This is not to question the content of the statement, but in the situation it seemed striking that I would bring up their role as refugees before her, while at the same time she had a fully quotable phrase ready as soon as I asked her about this. I

Implicit in this question is the understanding of the Palestinian right to return, meaning returning to life in the refugees’ respective place of origin in what is now Israel. 29

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Beyond Numbers: Political Fertility in Palestine encountered other such situations in which mothers would state their willingness to sacrifice their children in the struggle for a free Palestine without blinking an eye. The children are a large part of the positioning of Palestinians in relation to the conflict. Children were referred to in connection to Palestine, as the mothers calls them the “future for our country” (H264) or “the force to face the world who in its majority [is] against us” (D141). Fertility becomes entwined in the positioning of Palestinians as fertility rates are paired with the risk of death for the children in the camp due to the Israeli soldiers and military operations. As a niece of one of my informants said: “of course in our situation as Palestinian, this [decreasing fertility rate] is not good. When small problems happen on check points, we might lose 2, 3 or 4 or so children.” (B255). Firstly, she positions Palestinians as being in a special situation in which a decrease in fertility is undesirable, since Palestinians lose their lives more frequently than people in other societies. Secondly, she refers to the situations at the checkpoints that cost the lives of up to four children at a time as ‘small problems’, again positioning the action of Palestinian children as minor, while the reaction of the Israeli military is framed as disproportionate. A second positioning that emerged is that of Palestinians in relation to ‘the West’. A mother talked of a Palestinian longing for children as something women in the West do not possess. She kept asking me why Western women do not have this passion for having children like Palestinians do, emphasising the differences she considered Palestinian and Western women to have. To make her point clear, she gave an example of Western women valuing having a dog over having a child: “[T]here are [Western] ladies who do not even have children, they have a dog and [...] considers this dog more valuable than [...] children…” (A469). She hereby implies that Palestinian women would never place an animal above their children. Another example of positioning in opposition to the West was that of a mother who said: “maybe the western people think that Arabs or Palestinian are socially retarded and that they keep on having children, but this is not true, not for everyone” (D286). By this statement, the mother positions Western people as prejudiced and condemning, since she creates a position where thinking that Palestinians are having many children equals seeing Palestinians as backward. This positioning of Palestine in opposition to others, be it Israel or the West, is somehow two-sided, as these are also represented as having some desirable appeals. While on one hand resistance towards the occupation by Israel is present throughout 66

II) Being Palestinian: Palestinian Positioning my material, the use of the health care system within Israel is on the other hand also present. As the infertile mother described, she used the medical system of Israel extensively. Despite it is an occupying power, Israel has a quality of care that my informant wants and that she can access. She seemed very aware of going to the oppressor for help, since she made sure to ensure us that she does not “take anything from them; not social security” (E97). It is as if she felt a need to ensure us that she is not using all the services that she could, e.g. social services to defend her use of the Israeli health care services. The same informant also expressed wanting something from the donors present in Palestine and in Kalandia camp. She expects UNRWA to support her in financing infertility treatment and has received 700 NIS to cover treatment expenses. She thus also wants something from the “Western” world that is similarly positioned in opposition to Palestine. Perhaps this is why she repeatedly said that she did not receive anything from anyone but her family, despite the financial support she indeed had received from ‘outside’ the family. Furthermore, the way of life for the young couple I interviewed also shows this contrast between the very distinct positions of Palestinian identity being opposed to especially Israel. They were living in an extraordinarily luxurious apartment with modern interior design, a replica of a brick wall build on the concrete wall of the house, a large flat-screen TV on the wall and a huge American-style refrigerator with large double-doors. While sitting in this modern home in a concrete building inside a refugee camp build on a property given to his family in 1948, the husband talks of past generations’ large number of children as a sign of their ignorance and how having fewer children is the right thing to do. A longing for a modern ‘Western’ life away from poverty seeps into the conversation. Thus there is a positioning of Palestinian identity against Israel and the West, sometimes in harsh words, yet behaviour, life and aspirations are shaped within the same global discourse and are very much entangled. 7.2

The point of view of policy planners and health providers

The occupation and the Israeli military’s presence seep into the clinic as well. The clinic is by no means an island, nor a political refuge, since international politics plays a role in everyday practice. I will now present the point of view of policy planners and health providers in relation to positioning as Palestinian. 67

Beyond Numbers: Political Fertility in Palestine Daily life in the camp’s clinic is conducted in relation to a military power, manifested in the six meter high Separation Wall, barbed wire and surveillance 500 meters down the main road. The clinic was visited by fewer patients on days where there might be troubles at the check-point. On the days in September 2011 around president Abbas’ visit to the UN General Assembly during which he applied for membership for Palestine as a state, tension and nervousness spread throughout the West Bank. This uncertainty over what might happen influenced the number of patients that came to the UNRWA clinic. As opposed to 185-200 patients on similar weekdays, only 125 patients came to the clinic on the day of the opening of the General Assembly which was the day when most ‘mushkile’, ‘trouble’ in Arabic, was expected. According to the female pharmacist, it was precisely because “people in Kalandia are afraid something will happen” and therefore stayed at home, showing that the political situation can restrict the utilisation of health services. That day the PNA had announced demonstrations in Ramallah, but no official demonstrations at Kalandia checkpoint. At 11 am, one of the practical nurses took me and the young assistant pharmacists out in the street to have a look. From around the corner of the clinic, the Separation Wall and the checkpoint were visible. There was smoke and fire in the street next to the checkpoint, but not many people had gathered and cars and busses could pass. An ambulance arrived where we stood and a young boy of 14-15 years of age was rushed to the ambulance. The nurse translated that he was suffering from the gas and he was treated inside the ambulance. The conversation that day during the lunch break amongst the health staff centered on Israel, Abbas, Obama, and whether the roads would be closed by the Israeli military or not. The presence of (a fascination with) the Western world can be found in the pamphlets lying in the clinic. In the ANC room, on the top of the large filing cabinets I found stacks of pamphlets. In order to take a pamphlet, one had to go out of ones way, as they were not in a place where many would see them. On my first day in the ANC room, I saw a nurse giving four pamphlets to a young women, this being the only time I saw them being handed out. In the pamphlets on family planning, the majority of the illustrations are of Western parents (see Figure 8), most often with a single child. References to religion and tradition are made in the pamphlets. This, for example, is written about the withdrawal method:

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II) Being Palestinian: Palestinian Positioning “This is an old method (It was narrated in Saheeh Muslim ibn Jabir. We used to practice withdrawal at the time of the Messenger of Allah, peace be upon him, and he knew about it. The Messenger of Allah, peace be upon him, did not forbid us). [...].”30 (UNRWAB2). It has apparently been decided to refer to family planning methods in terms of history and with reference to religious scripts, thus presenting Western modernity as well as religion and tradition in the pamphlets, all in order to encourage the use of family planning. According to my informant in the MoH, it has been necessary to involve religious leaders and base the information material on quotes from the Quran, as a perception that Islam does not allow family planning is prevalent in the community. In my interviews with policy planners, several Figure 8. Frontpage photo from an UNRWA health brochure. The headline reads: “Benefits of Family Planning”. (UNRWA B2)

positionings also occur. In the MoH, my informant draws lines of internal positioning of Palestinians according to perceptions of development.

She describes Palestinians in rural areas as different, as son preference and large families are more important than in urban areas. Due to closures and their proximity to Israel, some places “have another idea, they want more children, they [do] not prefer to use contraceptive methods” (MoH371), hinting at political fertility. There is a touch of condemnation in her description of rural Palestinians, since she describes them as being from a ‘different culture’ while the urban Palestinians of Ramallah and Kalandia are termed as ‘open-minded’. She describes Palestinians in Gaza as different to West Bank Palestinians, offering a position of West Bankers (such as herself) as more rational and less emotional. She describes how Palestinians in Gaza prefer pills as a family planning method, as they want to be able to opt out of not having children faster than Pales-

“Saheeh Muslim ibn Jabir” refers to one of the major Sunni Muslim hadiths. In Islamic terminology, the term hadith refers to reports of statements or actions of the prophet Muhammad (Den Store Danske.Gyldendals åbne encyclopædi, 2012). 30

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Beyond Numbers: Political Fertility in Palestine tinians in the West Bank that prefer the IUD. She explains this difference as due to the Intifada and the political situation. In the interview with the MoP, Palestine is given a role as unique in terms of fertility. Positioned as opposed to Western countries, fertility in Palestine is seen as a policy area in which you cannot talk about the aim of decreasing the rate. He frames such a position in which one can talk openly about a desired fertility rate, in his wording, as a violation of the right of women to decide the number of children themselves. He is critical of the low fertility rates of Europe, and questions if Palestine should strive for such rates. Instead, he creates a position for finding a rate that suits Palestine, where human rights are the base of fertility. 7.3

Triangulation: Positioning Palestinian fertility

I have shown how a theme of positioning of Palestinians is part of my empirical material. These positionings offered are not surprising given the political situation and the everyday experiences of the refugees living in Kalandia camp. In this empirical material we have seen support for the argument of the previous chapter that adolescent mortality and imprisonment plays a crucial role in the Palestinian understanding of fertility. In the following section, I take an analytical stand on this empirical material by employing relevant analytical concepts and approaches from within the anthropological field. Firstly, I look at the positioning in relation to the occupying power and the statements on children and fertility. Here I use the concept of discursive phrases to open up my material through the frustration I experienced while conducting fieldwork. Frustration can be a sign that something is not merely what it seems, and can be analytically productive. Secondly, I analyse the positioning of Palestine and Palestinians according to constructions of a ladder of modernisation or development in relation to fertility. Here I am drawing on the research by Rhoda Ann Kanaaneh. 7.3.1

Discursive phrases

As shown in the presentation of the empirical material above, and not surprisingly the conflict plays a major role in my empirical material, and seeps into everything from clinical daily life to perceptions of fertility rates. The material is filled with terrifying statements and stories of injustice. As a mother puts it at the end of the interview: “each house in this camp has one [horrible story]” (G552). Imprisoned sons, the fear 70

II) Being Palestinian: Palestinian Positioning of small children being killed by soldiers when playing in the streets, soldiers going through the neighbourhood, is merely part of these stories of the life in Kalandia camp. I do not wish by any means to belittle or trivialise the statements or violations within my material, yet I also at times sat with a feeling of something else being in play, rendering reflexivity necessary. I will thus look at the material from a perspective of discursive phrases. In situations of conflict and collective violence, anthropologists have used a perspective of discursive phrases (Vigh, 2006:120; Gilliam, 2003:55) to understand the radicalisation of communication and ideology that they encountered in their fieldwork. Through living in conflict and war, ideology seems to transform from a system of understanding of an ideal society into a system of representation and positioning to distinguish who is who, and ensuring that one is not seen as the other. Ideology, usually understood as political ideals of how to organise and structure a society, becomes political slogans that serve to position people in social categories of friend or foe. In a conflict, positioning must be clear, and therefore statements become clear slogans, seemingly radicalised, and serving as a symbolic boundary between different positions within the conflict. As a result, it becomes difficult to propose alternative interpretations of a phenomenon, as this can be seen as taking the side of the enemy or as toning down the positions (Vigh, 2006). I occasionally had a feeling of being at a political rally or in the midst of a demonstration. The statements of my informants could have the ring of political slogans, a feeling of superficiality. As an example, one woman told me “[It] is a good idea that the Palestinian children are [the] strength in front of the world” (D141) and followed soon after with “they are willing to die in order to have their freedom” (D126). She was talking about her own children and relatives’ children, and yet she can without batting an eye tell me that it is positive that children fight and are willing to die in the struggle for an independent Palestinian state. The point here is not to discuss the implication of such a statement, but to use the perspective of discursive phrases to understand what leads her to say this during the interview. It can sound like a simplification and radicalisation of communication in order to position herself as pro-natalist, while at the same time letting me know that the position I represent (reducing fertility) is that of the ‘others’, the occupiers. Another example is that of the elderly mother who proudly showed me photos of her son with a rifle. She talked of the death, imprisonment and 71

Beyond Numbers: Political Fertility in Palestine injury of her three sons as sacrifices she had made for Palestine and repeated “they left me with no children” (G202), referring to the Israeli soldiers. Gilliam describes discursive phrases as entities that are repeated over and over again, having an air of truthful triviality, and by utterance refer to a large discourse that is common knowledge to members of a community (Gilliam, 2003:54). The use of such phrases thus does not necessarily entail subscribing entirely to an ideology, yet it can be a sign of talking the language of the community. Use of slogan-like statements like these about the national strength of having children, easily leads to questioning whether the pronatalism in my material is ideological or merely an expression of discursive phrases aimed at positioning and displaying nationalism to an outsider. In order not to be accused of making fertility decisions benefitting the occupying power, or the foreign donors’ agenda, statements perhaps become over-politicised. Being Palestinian and positioning oneself as such radicalises the statements of my informants, providing me with the rich quotes expected from fieldwork within a conflict setting, while simultaneously posing questions of what is at stake. 7.3.2

Development and modernisation

Another perspective that is helpful to open up the material on positioning is that of fertility’s role in symbolising modernisation and development. Globally, population and modernisation discourses have focused on the shift from traditionally high fertility, seen as draining a society in terms of development, to modern, low fertility seen as stimulating development of societies (Gould, 2009). Levels of fertility have thus been paired with a ranking in modernisation. Building on one year of fieldwork amongst Palestinians in Galilee in Israel, Rhoda Ann Kanaaneh analyses family planning processes. Kanaaneh argues that a narrative of modernisation is linked to reproduction in Galilee, creating “a complex and compelling web of new reproductive discourses and practices through which the modern and the backward are conceived and ranked” (Kanaaneh, 2002:252). High fertility and large family size are by many perceived as backward, while a small family size is modern. Kanaaneh argues that there is also a counter-discourse present amongst Palestinians in Galilee. This counter-discourse challenges the typical view through the same conceptual framework – but here, perceiving high fertility as being the defender of an Arab authenticity, and holding a political agency by upholding the family and the nation. Kanaaneh finds that the strategy of reproduction is an arena of resistance against the Israeli 72

II) Being Palestinian: Palestinian Positioning population policy, either by having large families to “outbreed Jews” or to have fewer children “to modernize them and thus […] challenge the Israeli domination with the quality of their children rather than the quantity” (Kanaaneh, 2002:18). By such thinking, reproduction is not just linked to modernism but also nationalism. Negotiations about social hierarchies through fertility, spacing and family planning are ongoing, entailing both this subscription to the common global discourse of small family size as modern and to the “counter-discourse of romanticized traditionalism” by which the family should be large (Kanaaneh, 2002:105). The traditional as well as the modern can be assigned both positive and negative values, spanning from “the debased primitive and the noble traditionalist” to “the modern enlightenment and modern poverty and anomie” (Kanaaneh, 2002:166). Kanaaneh shows that these constructions of modernisation are found even in the daily practice of family planning. Family planning pamphlets in Israel show Western parents with a single male child, and reveal a strategy of appealing to Palestinians’ desire for ‘modernity’ and middle-class status (Kanaaneh, 2002:78). A similar strategy can be seen in my material, albeit what is interesting is that the brochures of my material strive to appeal to modernity as of the West and to traditionalism through historical references and religion at the same time. Moreover, dreams of Western modern lives in places far away from the conflict, outside the refugee camp and without living on a refugee ID card are present in my material. A pursuit for modernity and development can be seen in the aspirations of mothers for their children, in health seeking behaviour and perhaps even in the modern luxury of a modern apartment inside the refugee camp. There are aspects of life seeping in from outside of the oPt. As Kanaaneh puts it, the Palestinians want the development of Israel or the luxuries of a Western culture, thus also subscribing to an understanding of a ladder of civilisation (Kanaaneh, 2002:81). In my material, the most prevalent perception of decreasing fertility rates by far that it is a symbol of modernisation and development. Having few children is open-minded and modern, whilst places with high fertility are seen as less developed. Family size can be a way of showing that you are modern and that developments have occurred since the time of your parents’ generation. While these are the perceptions the majority have voiced, the material is ambiguous. A few of my informants and a few statements indicate that whilst having fewer children is seen by the majority as a positive and modern development for Palestinian society, these are not perceptions shared by all. Having (too) few children is also seen 73

Beyond Numbers: Political Fertility in Palestine as problematic. It is viewed as running the errands of Israel, the ‘West’ or donors. Positioning Palestinians as opposed to exactly these entities, as an independent nation, it becomes a betrayal to have fewer children, as if it cannot be defended for the sake of Palestine. The statement of the mother who says the Palestinians are not socially retarded and don’t all keep on having children reclaims agency by signing up to a Western discourse of modernisation and development whilst simultaneously demarking the West as anti-progressive. Several times during this interview, she positions Palestinian children as the future and hope for the nation and the family, indicating that perhaps her statements are rooted in what Kanaaneh calls “romanticized traditionalism”. She opposes the interference of others (foreigners as well as health services) and believes that “no one can tell us how many children we should or should not have” (D268). Another highly interesting argument that challenges the unequivocal pairing of modernisation and development with decreasing fertility comes from my informant in the MoP. He said that we must remember the human rights of selfdetermination when talking about a state’s role in influencing fertility. No one should be allowed to decide for a woman how many children she should have, and by this he does not mean by force but also by means of the programs and interventions of a health, social or education system. He means that neither a Palestinian nor a Western state should play too influential a role in controlling its fertility rate, as it infringes on personal human rights. He is thereby using a ‘modern’ argument about human rights for not forcing lower fertility, and is thus creating and offering a position in which having a high fertility rate can be seen as defending the human rights of a people. These challenges to the pairing modernisation and development with decreasing fertility show the dynamics of defining perceptions of fertility at stake amongst Palestinians in Kalandia refugee camp. These are clearly ongoing struggles. According to a study on gender roles within Palestinian nationalism, Joseph Massad argues that modern European gender norms will suppress and thereby remove existing traditional norms, not leading to a cultural syncretism (Massad, 1995). Whether traditional perceptions of fertility in Palestine over time will become subordinate to perceptions of decreasing fertility as part of modern Western culture is not easy to answer. The politicization of fertility might suggest a different course.

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III) Having Children in Palestine: Beyond Numbers

8

III) Having Children in Palestine: Beyond Numbers

The third and final chapter of analysis deals with a major argument of my thesis: that fertility in Palestine is about more than merely numbers. I approached my fieldwork with an assumption that fertility was only a matter of numbers. For mothers, I expected fertility to be something along the lines of aspirations to have a family with a certain number of children. From the health providers I was expecting to hear discussion of fertility trends and the programs in place to support women to reducing their number of children in order to better the health and lives of Palestinians. And when approaching policy people, I brought with me the attitude of the literature that Palestine has a surprisingly high TFR and assumed this to be reflected 1:1 in the interviews. At the time I was leaping from desk study to field study and my questions reflected a pre-assumption that fertility was a concept revolving around numbers. This view of fertility was challenged by the field as other understandings of fertility appeared. The understanding of fertility in relation to numbers differs in my material, yet as a thematic entity ‘numbers’ is found throughout my material. My analysis shows that mothers do not think of their children in terms of numbers; policy planners do not want to speak about numbers; and in everyday life with reproductive health policies and services, de-linking fertility from numbers opens up possibilities for using and providing these services. Firstly, I present the empirical material on ‘numbers’ from the mothers I interviewed, and then from the clinic and the policy planners. In the third section, I analyse the arithmetic’ of having children in Kalandia and I then show how the association of fertility to ‘numbers’ makes the area politically tense. Finally, I show attempts to ascribe a meaning of timing of pregnancies rather than numbers to the notion of fertility drawing on concepts from the discourse theory of Laclau and Mouffe. This struggle on the meaning of the notion of fertility opens spaces of working with fertility and family planning services. 8.1

The point of view of mothers

During my interviews with the mothers, I asked questions about the reasons for having the number of children they had. It quickly turned out that this understanding of the number of children being the main aspect characterising having children was not reflected in the understandings of fertility amongst the mothers. When I posed ques75

Beyond Numbers: Political Fertility in Palestine tions about ‘why this number’, the typical replies were “it is all from God […] I have nothing to do with it…” (F118) or “I never thought of how many children I will have” (D227). The mothers would shake their head with skepticism. The presumptions of mothers having a plan for how many children they want had to be tossed aside. One mother, sitting in her living room, surrounded by her children and family members would verbalise that this child, nodding her head towards one of them, was not planned. Children just happen. Most of my informants would reply to my question of how many children they have, not by stating a total number of children, but by either explaining the sequence of children, presenting them individually, or stating X sons and X daughters, not a total number of children. This was not something the mothers made a big fuss about, albeit it is very consistent in my material. In my conversations with mothers I found some, factors, to me surprisingly tangible, influencing the number of children they have had. By tangible, I mean that the mothers do not refer to abstract ideals of family size, for example, but refer to more practical factors. Several mothers mentioned that once they were first married, they feared not being able to have children ‘naturally’ (without fertility treatment), and therefore hurried to have their first child to check their fecundity. Here the families, especially the in-laws, play an important part in pushing for a child soon after marriage: “Here the relatives like to see a baby immediately” (A93). The time from marriage and to the first baby is therefore often short. In my material it seemed that having the first child was merely the beginning. The timing of the next can be questional, but no one questioned the desire for the next child to come. Again and again I heard the statement: “One is not an option” (C74), and it seems that no one voluntarily stops after having had one child. The efforts of the mother of only one son, who had gone through several IVF treatments to have a second child, show her desperation. Having one child was not satisfactory, and she had tried for 10 years to have another child. A widespread notion I encountered was that of sibling ‘teams’. Children are expected to be the social security for each other later in life. Yet this notion of teams is gendered, in that the gender of the sibling matters. Mothers expect the course of life to be different for their daughters and their sons, and hence the notion of future ‘teams’ consists of sisters and brothers apart. A mother of two girls and two boys told me how her mother gave advice at the time she had her first three children: “She said that 76

III) Having Children in Palestine: Beyond Numbers since the Jews kill your children why don’t you have another son, a brother for your son, because God forbid, but he might just leave and die. You do not want a lonely child” (A135). The son needs a brother, someone on his team, and he is thought of as being an only child, regardless of his two sisters. Corresponding statements regarding sister-teams are also present. A mother of two girls and four boys said she had wanted another girl “so that my eldest daughter won’t be alone…you can never know what will happen in the future” (F109). As noted, a frequent term in the literature of fertility is that of son preference. In my empirical data this theme also emerged, yet in a context-specific manner of the conflict. Some mothers told me that son preference was a phenomenon only of their mother’s generation, of the poor and uneducated, or of Palestinians in Gaza. They said that for them, their daughters and sons were of equal value, and that the sex was not of importance to how many children they had. Other mothers told me that for them having sons was a necessity and an expectation of their lives, as the sons stay with the family after marriage and keep the family name. As in the quote above regarding the mother’s advice from her own mother, the most pressing factor for this mother to have a second son was the family’s concern that they might lose the first one. The brothers-in-law of this mother died as martyrs, and their portraits were hanging in the living room while she spoke. This family feared that the sons could be killed by Israeli soldiers, and as security they found it important to have another son. Another mother talked about how she is filled with fear for her son’s life when he plays in the streets of the camp. She fears that he will not return, either being imprisoned or killed by Israeli soldiers. This fear of losing a child affects decisions on number of children. 8.2

The point of view of policy planners and health providers

In the interviews with policy planners and health providers, talking about “number of children” was clearly a sensitive, and for some a controversial area. When posing questions about rates, family planning services and their effects on fertility trends, I would get some of these informants’ most engaged outbursts. The policy planners I interviewed would at times talk as if they were reading aloud from a report, but when we approached the topic of introducing family planning in Palestine, they would get up from their seats, and an atmosphere of choosing your words carefully filled the room. In this section I will present the empirical material on numbers stemming from the material from the clinic and the interviews with policy planners. 77

Beyond Numbers: Political Fertility in Palestine In the MoH, the informant said to me: “If I speak about numbers, it’s very sensitive because we have Intifada, we have many children, so the women [do] not prefer this family planning” (MoH93). This quote represents a common view of fertility understood as revolving around the number of Palestinian children and the notion of family planning as a method of decreasing this number. When talking about family planning services in a way linked to ‘numbers’, the MoH experiences that services are seen merely as a method for limiting the number of children: “family planning in our culture […] mean[s] limited [numbers] of children” (MoH84). And in Palestine, limiting the number of children is, according to my informant, perceived as being against Islam and as opposed to the aim of the Intifada. She tells me of a perception of the Quran opposing the use of contraceptives, and she also tells me that a perhaps more widespread opinion is that having few Palestinian children is inconsistent with the struggle for Palestinian independence and resistance against the occupation. The policy planners were very aware of the association of the conflict with the understanding of fertility: “[C]onflict has provoked people to have more children […] some were calling for more children, like Arafat saying that the demography is important, calling for more children. […] This is only solved when the political situation is stable because when people feel unsecure for economical or political reasons they will have more children” (UNRWA18). My policy informant in UNRWA hereby puts into words the linking of the conflict to the number of children people are having. In his view, a higher fertility will necessarily be the result of the conflict, as the insecurity forces people to have more children. However, it is the same politicisation of fertility that perhaps is the reason that the PNA does not have a policy on family planning or population for that matter. According to my informant in the MoP, he would rather go on without the creation of a policy on population for Palestine: “[E]specially as a Palestinian people [we] still consider this issue as a political issue. So sometime we [are] trying to deal with some programs without declare (sic) the clear policy issues.” (MoP70). Earlier in the same interview, he stated on behalf of Palestinians that “we are not ready” (MoP278), talking about a population policy. The informant told me that at a political level discussion about fertility rates and wishes for future rates are avoided by everyone. According to his view, the ar78

III) Having Children in Palestine: Beyond Numbers gument for family planning has to be about the development of Palestine given the resources on hand, as opposed to demographic arguments about the ‘appropriate’ number. The PNA should only encourage the number of children that the PNA can provide for, to “ensure the suitable conditions to life” (MoP83), yet due to their political situation of being under occupation, there are at the same time forces pushing for more children, or the “suitable fertility rate we need in Palestine to keep our vitality” (MoP643). 8.3

Triangulation: fertility is not (just) a number

In this final section of my analysis, I bring together the two previous chapters and show what is at stake in having children in Palestine as well as conducting family planning in Palestine. In the first section of this triangulation, I analyse the calculus of having children in Kalandia, and I challenge the understanding that political fertility inevitably leads to higher fertility. I show that the calculations done by mothers in Kalandia are shaped by the conflict. In the second section I show how it is the association of fertility with numbers that makes conducting family planning services so politically sensitive in Palestine. And I triangulate data from mothers, the clinic and policy planners to show how ‘spacing’ as an understanding of fertility emerges in my material. Fertility becomes not a question of numbers but of spacing. This is a major finding of my study: that fertility is about the timing of the children, rather than the number of children. Using the theoretical approach of discourse theory I discuss how fertility can be seen as a notion of constant negotiation and ascription of meaning. 8.3.1

Mothers do calculus without numbers

Having children as something that ‘just happens’ was by no means a surprise to me, nevertheless I approached the field assuming that a larger proportion of the mothers would express a deliberate choice of their particular number of children. For mothers, the importance lies with the individuals and not their place in national statistics. The number does not seem to be at the core of the way the mothers perceive their children, however they present highly politically considerations and arithmetic influenced by the conflict. Having children is the expectation of kin and the nation, and thus zero children is not an option considered within my material. The mothers I talked to did not perceive one child as enough and as a ‘sibling’ team consists of a minimum of two, and 79

Beyond Numbers: Political Fertility in Palestine most informants perceive having both daughters and sons as the ideal, the number of children in a family soon becomes a minimum of four. Expectations of parenthood are also seen in structural aspects, as the organisation of the health services in both MoH and UNRWA shows. The family planning services provided by these institutions are introduced while a woman is pregnant or immediately after her first birth, which means advice on contraceptives is not perceived as something given to women before the first pregnancy. Zero children are thus not the expectation of the institutions either. On the contrary, the UNRWA Family File is able to register up to twelve children for one family. The UNRWA clinics are not forcing mothers to have this number of children, yet apparently they expect that this might occur. Furthermore, the conflict plays an important role in the calculus of how many children to have. The vast majority in Kalandia camp knows of someone who has been imprisoned or killed, and arrests occur. While I was in the clinic, the clerk told of the arrest of his two nephews one morning. His colleagues had heard such stories before, and although they did react with condemnation of the arrests, they did not react by more than merely saying “ya haram”, ‘what a shame’. Such stories are not rare. The conflict is the most pertinent risk factor in Kalandia, it being so close to a military presence. The fear of losing a child or young man plays a role in the decision to have children, parallel to the role a high risk of infant mortality can play in other settings, supporting the claim presented in Chapter 6. To ensure not growing old without anyone to care for you and to ensure ones financial situation in ones old age, mothers are having more children merely from the risk of losing a child to the conflict. This is at the very core of the notion of political fertility – the conflict results in Palestinians having children, which they (perhaps) would not have had if the political situation had been different. This is how political fertility is portrayed in the scientific literature, exclusively as leading to higher fertility. However, with my empirical material I must challenge this assumption that the conflict always entails having more children than mothers would under other conditions. An example of political fertility resulting in fewer children is that of the implication of political resistance for the family. This is highly linked to the economic impact of the conflict and the value of not having more children than you can afford to care for. For the woman with three sons either killed, injured or imprisoned by Israeli military, the conflict has influenced, in a very tangible manner, her number of grandchildren. The son in prison was married before his arrest and has one son. He and his wife are not able to have 80

III) Having Children in Palestine: Beyond Numbers more children while he is imprisoned. Meantime, the woman’s daughters both have three children. According to the mother and the one sister I spoke to, three children was enough, as they are not able to care for more with the financial burden of the family’s situation. Imprisonment renders having children physically impossible, and the economic consequences of imprisonment or martyrdom hit the whole family and their financial capacity to afford children. Another way the conflict results in fewer children is “simply” via circumstances the occupation creates for daily life. A mother told me that as “the Palestinian lives in general is very hard, with the wall, the blockades, closers, and check points (sic)…beside the lack of good work” (D98), she does not want to have more children for the sake of the lives she expects them to get. Talking to other families made me think that their share of the fertility rate was far less influenced by the conflict, at least as a deliberate choice. Sitting in the bus in the afternoon traffic, in the midst of the bustling cars on the main road returning from an interview in Kalandia, my interpreter Maysoon, sitting on the seat next to me, said: “She is why we have high fertility” (OBS). Maysoon was referring to a mother of six children we had just interviewed. This mother lived in a rented house in Kalandia camp, and in the living room there had only been basic furniture, with no photos or ornaments on the wall as we has seen in all the other houses. She was of a lower socioeconomic position than the other informants, had no formal education and no political or economical reflections on having children; they came as a gift from God. She did not like to use modern contraceptives, as she told us that she and her husband had their own method. She was a mother of six children, pulling up the TFR. Both Maysoon and I were sitting in the bus thinking that these six children were not born as a result af a political action, however they could certainly still be a result of life under occupation. The empirical material shows that having children in Palestine is a set of calculations, and yet these calculations are done without a number at hand. Mothers do not end up with the same number of children after having done the calculus, and these calculations differ according to perhaps education, family structure and political involvement. The conflict has for some meant that they fear to have more children, as they are scared of losing them. For others the same fear as led them to have more children, so that a loss of one might not have the same consequences as if they had

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Beyond Numbers: Political Fertility in Palestine fewer children. The arithmetic of having children in Palestine is conducted with multiple factors involved and plays out in complex ways. 8.3.2

From ‘numbers’ to ‘spacing’

In this final section of the analysis, I gather together the analysis of what it means to be conducting family planning in Palestine. In the presentation of the empirical material, a resistance towards speaking of numbers came up, and I will here present my analysis of how a politicisation of fertility stemming from the association of fertility to numbers leads to a need for a balance between political positions. I conclude the section by presenting a main finding of my research: that in order to be able to act and provide family planning, fertility is talked about as spacing, turning fertility into a question of the timing of having children, rather than the number of children. “We are not speaking fertility or [of] high fertility or [of] we want to decrease the number of children, no.” (MoH258). In this statement, ‘speaking fertility’ is juxtaposed to ‘speaking high fertility’ or to ‘wanting to decrease the number of children’. ‘Speaking fertility’ is seen as something unwanted, due to the perception of fertility as a concept that entails a reduction in number of children and causing loss of control over a family’s right to children, as described earlier. This was repeated in the clinic and in the offices of policy planners. In the MoH my informant underlined that they do not force family planning upon anyone nor do they have an objective of lower fertility. On the contrary, my informant assured me: “She can deliver any number she wants” (MoH505). For all my informants ‘behind’ the family planning services, it was crucial to emphasise that the decision to have children or to use contraceptives lies with the women, that it is a human right to choose. To this day, the notion of fertility in Palestine is associated with the number of children as a political factor. My informant in the MoP explains the association of having children with the occupation by the statements of Arafat: “[W]e still suffer from some statement about the “Our struggle is demographic struggle” [in] our work” (MoP76). According to him, the link between fertility and politics obstructs conducting family planning for the health providers. The politicisation of family planning means that handing out a condom or inserting an IUD can be seen as an action aimed at reducing the number of children, leading to fewer Palestinians and thereby a deterioration of Palestinian strength in the fight against the occupation. This poses predicaments of political positioning. 82

III) Having Children in Palestine: Beyond Numbers Whether or not to have more or fewer children is seen as a question of taking sides. The wish for family planning “comes from foreign, from overseas, this is maybe support[ing] the Israeli policies. ‘You need us to decline our population growth’, ‘no, we need more people’” (MoP80, quotations added LNH). The dualism of the Palestinian need to reduce the fertility rate in order for the PNA to “ensure the suitable conditions” (MoP83), yet ensuring an adequate number of people “to keep our vitality” (MoP643), constantly poses a dilemma for policy planners. Policy planners are thus balancing and navigating through a politically tense sphere. This space of positions in which to navigate and operate in seemed to be different for the informants according to which organisation they work for. While both informants from the PNA told me that they experienced the areas of fertility and family planning as sensitive, the situation seemed quite different for informants from within the UN. Especially within UNFPA I got the impression that this area of work had not yielded many conflicts, since my informant seemed genuinely surprised when I asked whether she had met any resistance towards family planning programs. My informant in the MoP repeatedly insisted that work with implementing family planning services and ensuring access to contraception was best done without too much focus on ‘numbers’. The resistance towards having a policy within the PNA was presented by him as a way to avoid politicising this policy area by de-linking a population policy from the family planning services. By not having a policy, the policy planners are able to provide family planning services and programs without opponents being able to critique them politically. If they had a policy, the services and programs could be claimed as being an attempt to decrease Palestinian fertility. From the point of view of my informant, it is possible to conduct family planning in terms of health and not numbers only as long as this sensitive area does not have a policy. Along these lines, UNRWA has been able to introduce family planning methods. My policy-informant in UNRWA, told me that: “with health it was able to make the argument for [family planning], not by demography” (UNRWA81). By putting emphasis on the health aspect of spacing as family planning it became possible to gain success with family planning programs. Enabling family planning services locates my informants within a globally dominant health political discourse ensuring women’s rights and health, positioning them positively with respect to the outside world. Meanwhile there are considerations and arguments within the conflict discourse encouraging having more Palestinian children as resistance to the occupation and to defend the right of existence. On the policy 83

Beyond Numbers: Political Fertility in Palestine level, numbers seem to be conceived of as a political entity and a sensitive issue. It thus becomes crucial that family planning is not linked to how many children women are having, as it should not be seen to be controlling this part of Palestinian life, and it must not be seen to be Palestinians doing the dirty work of the outside world’s agenda of decreasing the number of future Palestinians. It is a fine balance for health policy planners and providers to master. In my material I discovered that when I spoke of family planning and numbers, my informants led me to talk about spacing of children – of mothers to have breaks in between their pregnancies. Recalling the definition of family planning, the WHO refers to family planning as “[a] woman’s ability to space and limit her pregnancies” (WHO, 2011). Here both ‘space’ and ‘limit’ are used to describe what family planning does. These two concepts are quite different – perhaps not in practice, but certainly in the perception of fertility. Also stated earlier are the positive effects of spacing on the health, wellbeing and outcome of the pregnancy. With this in mind, I will now unfold the empirical material I have on spacing and limitation. The policy planners and health providers go out of their way to frame it as spacing and highlight the health improvements for the mother and the child. The recommendations of the MoH and of UNRWA are set in a sphere of spacing the birth of children, not of influencing the number of children. However while the latter will automatically be a result of the former, this is not mentioned. Instead, the services are run with an emphasis on the health and development of the mother and child. In a brochure on the benefits of family planning found in the ANC room in the UNRWA clinic, the first line translates as: “The purpose of using family planning methods is to separate between pregnancies in order to have the desired number of children and maintain good health of the mother and the whole family” (UNRWAB4). And in a brochure presenting the IUD as a contraceptive method, IUDs are called: “Methods of spacing between deliveries” (UNRWAB3). According to my informant in the MoH, spacing is more acceptable than family planning for mothers and their families. In my interviews with mothers, it was also spacing and not birth control (or family planning) that resonated in the talks about contraceptives. Mothers would themselves refer to the term ‘spacing’ as they talked to me about contraceptives. A niece of an informant I interviewed in Kalandia, rephrased the wording of my interpreter. Maysoon talked about the availability of ‘birth control’ methods, when the niece said: “yes, that’s true…they try to make us aware 84

III) Having Children in Palestine: Beyond Numbers and to space between children” (B231), and thus rephrases contraceptives from birth control to spacing. In my material, spacing seemed to be conceived of as a positive and modern thing to be able to tell me, a stranger from the West, about. A mother of four children talked about family planning only by referring to spacing. When she wanted to explain to me that her husband is religious, but not fanatic, she used as an example that “[h]e believes in spacing between children and using contraceptive “(B115). By this statement she places spacing and contraceptives in opposition to religious fanaticism to construct spacing as a positive and modern way of thinking. By the framing of fertility related health services as a way of spacing children, fertility becomes about the timing of having children, not about the number of them. This is in line with the resistance to talking of the number as seen in my material. In this way, having children becomes a question of when and not of how many, thereby seemingly losing its political tension. Offering an alternative meaning to the notion of fertility can be seen as an expression of a need to challenge a dominant perception of family planning as being about numbers, demography, and a tool to control the number of Palestinians. This latter perception has been so dominant that an alternative meaning of the notion of family planning was required in order for women to see family planning as acceptable, and not as a political tool to control their lives. The linking of family planning with spacing in order to challenge or avoid the general understanding of family planning as being about limiting the number of children is not new and not only seen in Palestine. Extensive research in more than 50 developing countries has looked into whether family planning was used as a way of spacing births or of limiting family size (Westoff & Koffmann, 2010), and the importance attached to spacing of over ceasing childbearing in Africa was studied 20 years ago (Page & Lesthaeghe, 1981). Moreover, there are regional differences in the relation between spacing and limiting (Cleland et al., 2006). In the local context of Palestine, Bosman et al. find that due to a widespread resistance towards family planning, contraceptives were promoted to protect health and not to reduce the number of children (Bosmans et al., 2008). Also, in the work of Kanaaneh a pattern similar to that of my empirical material emerged. A deliberate use of the word ‘spacing’ and avoidance of the use of the word ‘limiting’ was found in family planning programs in Palestine (Kanaaneh, 2002:75).

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Beyond Numbers: Political Fertility in Palestine By viewing the understanding of fertility through concepts by Laclau and Mouffe opens up for analysis how the political definition of the notion of fertility and the understandings of family planning are being constructed. Taking as a point of departure the theory of formation of discourses, useful analytical tools appear, and the component of constant negotiation of ascription of meaning is of special assistance here. Discourse theory takes as a point of departure that a social phenomenon is never complete or total, meaning that they will never be clearcut or without ambiguity. The social field can be understood as a web of processes of ascribing meaning, making this ascribing central to the theory (Jørgensen & Phillips, 1999:35). Exactly such a ‘fight’ over ascribing meaning to the notion of fertility is what I have discovered in my material. Fertility and the related reproductive services are seen as either family planning or birth control or as spacing. Family planning and birth control is in my material seen as bringing with it an emphasis on numbers, whereas spacing is thought to be about timing, rather than numbers. In my material it seems that the understanding entailing numbers dominates other understandings. An aim of the discourse theory of Laclau and Mouffe is in fact to look at the processes of struggle over the meaning of signs. This meaning will never be stable, but will be an object of constant negotiation (Jørgensen & Phillips, 1999:39). Competing meanings will constantly destabilise any certainty about the notion of fertility, and every articulation of fertility or family planning services will reproduce or challenge a given discourse in which fertility was assumed to be without this multiplicity of meaning. But as the meaning of this notion of fertility is never complete or total, it is a constant struggle. By framing fertility and family planning services as spacing and thereby de-linking the notion from revolving around numbers, the health aspect of fertility gains more importance and weight. This results in a de-politicisation of the notion of fertility in an attempt to take focus away from numbers and fertility rates. Hereby the content of the notion of fertility seems to be challenged and re-formulated by the Palestinians, both within a policy sphere and in the understandings of mothers. In a creative process, the notion of fertility becomes something else dynamically. Spacing will also entail fewer Palestinians, as will family planning or birth control, yet when ascribing the meaning of spacing to fertility the services becomes something one can speak about. Fertility is ascribed a meaning of health above other meanings in such an articulation. Thus a necessity for contraceptives in order to achieve good health and financial development is constructed. And hence, the perception of mothers, health providers 86

III) Having Children in Palestine: Beyond Numbers and policy planners about the notion of fertility are expanded from being solely a matter of (politically loaded) numbers. Through the statements of the mothers, in the work of the policy planners and in the daily clinical practice, the understanding of fertility as revolving around numbers and family planning services as control of these numbers is constantly challenged and the content of these terms negotiated. Reformulations and ascription of alternative meanings depoliticises notions, whereby new spaces for acting occur. By offering spacing as an alternative meaning of fertility and of the health services of family planning, it becomes possible to use as well as provide these services in situations where such use and provision is questioned for its political motives. As my informant in UNRWA said, it was through health they were able to introduce family planning.

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9

Discussion

In this chapter I discuss the methodological, analytical, contextual and theoretical considerations of this study and the implications for my findings. In the first part of this chapter I discuss methodological choices, before discussing the research process in relation to certain quality requirements for qualitative research and ethnographic validity. Thereafter I bring ethical considerations into play. Finally I draw perspectives on the public health relevancy of this study. 9.1

Discussion of methodological choices

Every choice made in connection with conducting research, from the very first seed of attention to the field to the final product, should be made according to the purpose of the study and thus entails argumentation. However, given the scope of this thesis, I have chosen to bring forward certain choices in my research process that are of greatest influence to the conclusions I am able to draw based on the analysis. The selection of informants was done in order to accommodate as great a number of nuances in relation to the research question as possible, giving both the rare and the common statement the same importance in the analysis (Christensen et al., 2011:71). Whilst the choice of an analytically broad spectrum of informants has meant a tradeoff in the level of detail and depth into each sphere, it has given me the analytical strength of comparison and validation across the field of fertility. The choices of informants have allowed me to shed light on fertility from within a policy sphere, and political talks in a high-level policy arena. The observations in the clinic have exposed how such policy come into play in daily clinical work and how family planning is then conducted and perceived in relation to patients, mothers and future mothers. In addition, including the perspective of these mothers brings up yet more new perspectives and offers understandings from within the minds of those that ‘embody’ political fertility. Infertility as a category is an example of how the triangulation of informants lets me understand the pressing issues across the field and look further into any discrepancies between the different agendas. Meanwhile, these informants, the extent of the empirical material, and the scope of this project will not be representative of all positions within the field of fertility in the occupied West Bank. Access to the field in terms of informants and setting was very much determined by one main gatekeeper, namely Dr. Khammash. Through the 88

Discussion network I build up during an internship in spring 2011, I was able to access the UNRWA clinic and the mothers using this clinic. It was also through this network that I was able to make appointments with policy planners. Dr. Khammash has been central for this access, and if it were not for him I would not have had such access to this field. Equally, he has also functioned as a gatekeeper in the sense that his perception of the field, of the relevant and important actors, as well as his social relations to the different stakeholders have meant that there are certain people I have not talked to. This is most influential in relation to the clinic and the policy makers, as he or his network had no direct influence on the selection of which mothers were to be interviewed. Dr. Khammash recommended Kalandia clinic out of consideration to the objective of the study due to its geographical position in proximity to the checkpoint. He continually ensured me of the representativeness of this refugee population compared to other refugee populations within the West Bank in relation to sociodemographic factors and living conditions. Yet the clinic in Kalandia is one of the least overcrowded, hereby showing the work of UNRWA in the best possible light. The gatekeeper function of Dr. Khammash is important in the selection of policy planners since his network and relations have determined whom I have met. Due to his position and his extensive work in the field of reproductive health, his critical approach within this field and his excellent grasp of the aim of my study, I feel confident that he put me in contact with those who are most relevant. Inevitable, there are policy planners that I have not met who can shed additional light and new perspectives on the matter. Here is it necessary to comment that I have not set out to conduct a mapping of all actors on the policy scene of fertility in Palestine, as that was not necessary to shed light on the research questions. On the level of Palestinian refugees, I have chosen only to speak to mothers. In one interview, I included the husband which allowed me to hear their shared experiences and observe gender roles within this couple. The outcome of this interview supports me in my presumption that conducting the interviews alone with the mothers without their husbands’ presence would mean that they would talk more openly. The gender roles would likely have meant that the husbands would have taken over, and the data would have excluded the views of the women. Yet with the choice of informants I made, the point of views of fathers or husbands is not included, and therefore remains to be heard. In addition, infertility turned out to be an important aspect of the perceptions of

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Beyond Numbers: Political Fertility in Palestine fertility amongst the mothers I interviewed, and it would therefore also be interesting to hear from women that are not mothers. Furthermore, a wider range of methods could have helped shed light on additional aspects of political fertility. Focus group discussion amongst mothers might have given insights into collective understandings of political fertility, whereas participant observations at the level of the policy planners could have yielded insights into the political practice within this highly sensitive political area. However, language skills and the short duration of fieldwork restricted the possibilities of methodological choices. My limited Arabic language skills restricted my access to many aspects of the field. I have only been able to access English scientific literature through my systematic literature search, precluding me from accessing research published in Arabic. I conducted additional literature searches while in Palestine with assistance of Arabic speakers to reduce this bias. In the observations, my limited Arabic limits the aspects I was able to observe. However, the most crucial role of the language barrier is having to conduct interviews with an assistant. I see the role of my research assistant as interpretation rather than translation, as she brings with her a layer of interpretation that cannot be overlooked. The layer of interpretation plays an essential and necessary role, also in the frustration over the lack of depth in some of the interviews I conducted with mothers. Especially when interviews turned to socially or politically sensitive areas, they would turn into a conversation between my research assistant and the informant (and at times a family member). While I tried to participate, I depended on Maysoon to translate. It took us a few interviews to find a set-up that enabled me to ensure I understood the details of what was happening, and hence got to ask additional questions. The roles of age and motherhood played an important role in the relationship between Maysoon and myself as well as between us and the informants. As the process went by, I took more responsibility for the process and lead the interviews more. Hereby the empirical data collected became more relevant to my purpose, and I was able to follow better a line of inquiry to obtain more detailed accounts. I could possibly have been less reluctant to ask questions during the sensitive parts of the interviews to gain more depth or have spent more time with the informants. I interviewed the women once, thus not enabling for a relationship to develop. Longer fieldwork could have counteracted this. 90

Discussion 9.2

Discussion of quality of research

For the discussion of the analytical quality of this thesis, I lean on the five requirements of quality of qualitative research put forward by political scientist Hanne Fredslund and sociologist Lisa Dahlager (2005), in addition to the approach of ethnographic validity by Sanjek (1990), presented earlier. As knowledge is understood as partial, positioned and situated, it is not a question of reliability as in positivistic research, but of validity and hence the basis of the choices that lie in the creation of knowledge must be made explicit to the fullest extent possible (Sanjek, 1990). The first requirement set forth by Fredslund and Dahlager is to be open, sensitive and flexible in the process of understanding, and refers to ensuring reflexivity throughout the research process. It is central for the knowledge that is obtained that the researcher is open to the field rendering sensitivity, a precondition for meeting the field that one wants to explore. The researcher must be able to create a position from which the knowledge can emerge. In respect to this first requirement of sensitivity and openness, aspects of positioning must therefore be discussed as to what knowledge can be created from where I position myself. In all situations in which I collected data I cannot remove myself from the process of data generation. The understanding I bring into the interview situation plays an important role in what I take with me from the field, in what I have seen analytically as well as for what was being said and done during data collection. As an example, reading my field notes I see the influence of my public health background as I noticed certain things in the clinic that have to do with the organisational set-up. A strength of coming as an outsider lies in my capacity to see such systems, assumptions and existing understandings from another perspective, and being able to question the current way of acting. Yet the conclusions that can be drawn from fieldwork can only express something in the light of the positioning, both of my background and assumptions about the field and vice versa. Hence, the way in which I am perceived by the field equally influences the empirical material. By virtue of my background I represent a Western biomedical world preaching low fertility and family planning. This was brought up for example by the mother who criticised Western people for thinking of Palestinians as socially retarded due to their high fertility. In this interview, the data has certainly included the aspect of positioning Palestinians as politically reflective and with agency, something I have incorporated into my analysis. On two occasions it became clear that the 91

Beyond Numbers: Political Fertility in Palestine mothers were hoping I could help them with their financial and social situations. Their view of me as someone able to help them can have meant that they put more emphasis on their economic hardship or desperation to have a second child than what these aspects are set forth to others. Such positioning of my role renders a critical distance to the statements necessary, and in the analysis of these statements I have attempted not to overemphasise aspects of their financial or social situation. In addition, my age and marital status also merits a comment. Being 27 years of age, not married and without children of my own positioned me as an outsider, and in certain situations there are things my informants would have told me if they could relate to me as a mother for example. The population of Kalandia is used to the foreign presence, and are hence aware of the expectations to what they will say. One older mother I spoke to mentioned that journalists often come to hear her story and take her photo. Thus in my interviews, there are a set of expectations of what I want to hear, and this also shapes the material. I have tried to be aware of this positioning in my empirical material and have therefore chosen to take a step back by discussing my empirical material in relation to the concept of discursive phrases. This can lead to a circle of overstatements and exaggerations, and it is therefore important to see the empirical data in this light. By analysing some of the statements of nationalism and fertility, I wanted to show that with my choice of methodology and informants there is a danger of only seeing what I came with an expectation of seeing, namely a preinstalled picture of political fertility. Another aspect of the first requirement of quality is the flexibility of the researcher throughout the research process, and flexibility is the practice in which openness and sensitivity are put in play (Fredslund & Dahlager, 2005). This means that the methods, for example, have to be able to be changed and shaped by informants. As an example of this, I revised my methodology in the clinic. Prior to the fieldwork, I had conceptualised the clinic as the place from which social practices could become part of my empirical material via observation, but during the process I made the decision to also conduct informal interviews with health providers, as the opportunities to observe the social practices of consultations turned out to be limited. This limitation thus became part of my empirical material in the categories of privacy and confidentiality. Furthermore, as I have attempted to show in the analysis, I changed focus and my interview guide according to what emerged from the field connected with my position. Infertility appeared as a category in my empirical material, which I had not fore92

Discussion seen, but I then chose to pursue this. Moreover, the emphasis on numbers in my initial interview guides was ‘toned down’ in order to give space for the understandings of mothers to appear. These observations have been built into the analytical work to ensure that the conclusions are build upon an open, sensitive and flexible analysis. The second requirement of Fredslund and Dahlager for ensuring quality is transparency, and resembles somewhat the concept of the ethnographic path Sanjek put forward. In order to evaluate the validity of the resultant knowledge, the choices and conditions for understanding must be made visible (Sanjek, 1990; Fredslund & Dahlager, 2005). Through my literature review and the presentation of my methodology, my introduction to the field, and throughout the presentation of empirical material and analyses, I have attempted to describe how I arrived at my research questions and choice of methodology. An aspect of the transparency requirement is to account for how the process of understanding progresses (Fredslund & Dahlager, 2005). In my negotiations over access to the field I had to change my problem statement, as I met challenges with access to the main area of participant observations I had planned prior to fieldwork. I arrived at the clinic hoping to observe consultations on family planning between health staff and patients in which theoretical understandings of policy would transfer into lived practices and relations. It then turned out not to be possible to participate in such meetings on family planning. Firstly, there were no community/group sessions on family planning, as the counselling is done one-to-one in the ANC room. Secondly, it was much harder to be allowed access to the ANC room than the rest of the clinic due to the personality and privacy policy of the midwife running the ANC room. This was understandable and I of course accepted her refusal of my participation in such sensitive counselling encounters. On occasion, a nurse was running the ANC room and she would invite me in. I could do some observing when this opportunity arose, but as I do not speak Arabic the outcomes were limited. According to Tjørnhøj-Thomsen and Whyte, the ongoing negotiations over access and the encounters resulting from these are themselves empirical material (2011). This meant a change in my problem statement from revolving around reproductive health encounters in a clinical setting. My idea of following the way family planning was talked about during these encounters was, as a result of access and language, not feasible. For this reason I changed my problem statement from revolving

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Beyond Numbers: Political Fertility in Palestine around the clinical encounters to focusing on the understanding of fertility in the clinic, at a policy level and among mothers. The third requirement is related to theory. Theory can be used and understood in different ways but the important aspect for the validity of the research is that the understanding of theory and its subsequent use is consistent and productive. The research field and the theory must therefore continually be confronted with one another. Also, this requirement is parallel to that of Sanjek’s assessment criteria. To Sanjek, theory is the filter that makes the empirical material more selective and systematic, and this lets us avoid the study of ‘everything’ (1990:398). This study is empirically driven and theory, as presented, is used as a can-opener. With a framework based on the demographic theory of the determinants of fertility, namely one concept, political fertility, I have used theory to pin down my research interests prior to fieldwork. Hereafter I have used theoretical understandings of what power is in this field and where this can be seen (biopolitics), as well as understandings of discourses to see how aspects can be framed (for example, used to understand statements about what family planning is). I am aware that the main theoretical understandings in relation to fertility (that of biopolitics for example) that I had brought with me when stepping into the fieldwork, have shaped the field and my analysis, yet I have also actively worked to include other theoretical aspects (for example the discussion of discursive battles) during the analytical work. To achieve reflexivity and to ensure an ongoing interplay between the empirical material and theoretical concepts, I have found it important not to choose the analytical aspects completely beforehand. With my choice of analytical strategy I have strived for an openness towards the empirical field and material, letting themes I did not expect to find emerge and giving them space, as the case of infertility is witness to. Hence I have used theory both while planning fieldwork and theories of significance as the analysis takes shape (Sanjek, 1990). This is in line with what Fredslund and Dahlager coin horisontal coherence part of their fourth requirement, that the line from a to b is clear and that all steps have been meticulously taken (2005). I have been through my material again and again, and sought to repeatedly challenge the different cuts through my material that I came up with. In the first attempts of analysis I was operating with an analytical dichotomy of perceptions being either political or nonpolitical, yet this categorisation seemed to be holding back the analysis. I realised that 94

Discussion assumptions about what is political and what is private was counterproductive given my empirical material. As it became evident that political aspects were present in all the empirical material, I instead applied a more open analytical approach. However, it is still important to question whether the analytical concepts and my theoretical framework have helped me in opening up the empirical material, examine what it is I have not been able to see in my material as well as consider what other theoretical concepts could have added. The understandings of power, biopolitics and discourse are inspired by the work of Foucault. When borrowing theoretical concepts from studies foreign to the local context, the impact on the findings must be considered (al-Malki, 2011). Nevertheless, the concepts of power and biopolitics seemed to fit very well with the empirical material, although whether this is due to the long colonial past of Palestine or the academic position I bring with me is difficult to answer. Still, I have been careful not to force a rigid theoretical model onto my empirical material, but used the concepts as ‘can-openers’ thus supporting the choice of an empirical rather than a theoretical emphasis in this thesis. The ambition to bring theoretical concepts to the table can be productive and create innovation, yet at the same time there is a danger of overlooking aspects of importance, overruling the value of insiders’ perspectives, or making assumptions unfounded in reality. In attempts to avoid the pitfall of conducting an analysis that is useless for Palestinians and seems external to the context, I have consulted with former colleagues from the health field in Ramallah throughout the process in order to ensure as much a local understanding of my material as possible. Furthermore, the choices of theoretical concepts lead me to see certain aspects, while others are cast aside. There are interesting aspects of my empirical material that I have not had the chance to unfold. I expected gender to play a larger part in my analysis, yet this did not emerge. As I have spoken to mothers only there are things neither I nor the informants would question, implying a risk of gender aspects being a blind angle in my material. Moreover, factors such as class or religion would have been relevant to uncover. The fourth requirement revolves around coherence. According to Fredslund and Dahlager, the most crucial aspect of this is the vertical coherence (2005). It is crucial to create a clear position of the theory of knowledge that is retained throughout the process. This is the aspect of coherence between the epistemology, the methodologi95

Beyond Numbers: Political Fertility in Palestine cal choices, the research object and the theoretical concepts. Embarking on a project with a methodology somewhat different to the most commonly employed approach to fertility in public health has proven to be challenging, yet it has yielded substantial insight. Ethnography, demography and public health each entails a different epistemological position. By using current knowledge from demography I have been able to identify exactly where there is a gap in knowledge – the understandings and perceptions of political fertility – and with ethnography am able to shed light on this area. Applying a methodological approach ontologically different to that most often used in the field I address has created challenges throughout this research process: in choosing informants, writing style and many other examples. Finding a balance between the specificity of ethnographic writing while positioning oneself in a field that is build upon the quest for reliability and generalisability of the demography that is often linked to positivism, has posed challenges in the process of writing this thesis. The fifth and final requirement is that of transferability or analytical generalisation. A fundamental aspect of epistemology is that findings cannot be seen out of the context from which they have emerged. Yet whether the conclusions can be said, at least to some extent, apply in other contexts can still be discussed (Fredslund & Dahlager, 2005). The influence of the context is at the core of such discussions, and political fertility is likely to be a factor in other communities in the West Bank or amongst Palestinians elsewhere. The perceptions of fertility amongst mothers living in Kalandia camp is one thing. They are the perceptions of women living in a refugee camp, embodying an refugee identity with all the social expectations and roles ascribed by the surrounding Palestinian community as well as internationally that that entails. It is also the perceptions stemming from women living with a military checkpoint, and occupying Israeli soldiers nearby, with frequent confrontations, and within the reach of their young sons and daughters. The geographical setting of the refugee population of Kalandia makes the findings relating to the proximity to the checkpoint, such as the fear of losing adolescents to imprisonment, less likely to be found in other populations. Yet the political sphere and statements are the same for the rest of the West Bank, and though there are large socioeconomic inequalities within the population of the West Bank, they are all under occupation. The findings related to the discourse on family planning, which we have seen also in Kanaaneh’s research as well as in other parts of the world, are likely to be present elsewhere in the West Bank. For Palestinians in Gaza, the concept of political fertility is thought to be more prevalent, 96

Discussion outspoken and influential (Courbage, 2011a), and thus the findings of this thesis will likely also apply to some extent in Gaza, bearing in mind the differences in political and economic situation between the West Bank and the Gaza Strip due to siege, blockades and internal political conflicts. “Palestinian society constitutes an exceptional analytical and research challenge” (2011:195) sociologist Majdi al-Malki writes, and argues that Palestine is an unsuitable environment for research (al-Malki, 2011). The context of this research is unique, making it difficult use the findings in other settings. However, the level of particularity differs in my findings, and while the adolescent imprisonment risk will perhaps not resonate in many other settings, the point of including political consideration into the understanding of fertility can be useful throughout Palestine and in other conflict settings. Also, a point of discrepancy between the importance given to infertility amongst mothers and on a policy level can be of significance in health settings all over the world. Studies of extreme or critical situations should not be overlooked for analytical generalisation. In the extreme lies the possibility of viewing more clearly aspects that can also be in play in other situations in which they are less obvious. Often such studies can produce an insight into key variables that are also useful in other situations. 9.3

Ethical considerations

Informed consent I, as the initiator, have a responsibility to ensure no one is taken advantage of or being harmed by the research I have conducted. When involving others in a research project one must aim at doing a minimum of harm to those involved and to ensure that they know what they are involved in and how they and their statements will be used (Hammersley & Atkinson, 1995). As my data collection spans a number of settings I employed a number of methods to ensure informed consent. During interviews with policy planners I would start by telling them about my aim and letting them know they could stop the interview at any point, refuse to answer any question or withdraw statements without explanation. With women informants, Maysoon would let them know this as well as informing them that they would be anonymous and that their name would not appear in the

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Beyond Numbers: Political Fertility in Palestine data31. We would reaffirm these rights several times during the interviews. The former situation was different, in that informants were not replying as private persons but in their professional capacity. This is a fine balance, as everyone is also a private person, but in the interview situations I judged that none of my questions were too personal for him or her to answer. Obtaining informed consent from informants that I interviewed due to their role as a representative of their position, out of their private sphere, raises questions of expectations for them of what they are allowed to say and the internal hierarchy that they operate within. These are issues I will never be able to fully grasp and I can do no more than trust that my informants will not say more than they wish to, while being constantly attentive to their behaviour and acting accordingly. Conducting interviews and involving other individuals demands a high level of situational ethics (Tjørnhøj-Thomsen & Whyte, 2011:113). In none of my interviews did I ask for a written consent, as I was advised not to by both my assistant and my co-supervisor. When conducting participant observations the concept of informed consent changes noticeably (Hammersley & Atkinson, 1995:264). In the clinic I hung a poster in the clinic explaining my presence (with a photo for visual recognition) (see Appendix V) and only an oral presentation at the clinic for those who I set up interviews with. I was told by local former colleagues or clinical staff that Palestinians do not like spending time reading and that posters and brochures are hardly ever read. Perhaps no one read my poster, perhaps none of the patients understood what I was doing in the clinic and perhaps this means that I did not ensure consent from the people who are the backbone of my observations. So is the concept of informed consent merely a false perception of ethical conduct? Do my introduction and oral statement of the possibility of withdrawal secure the rights of the informants? Ethnographic fieldwork with observations and informal conversations has a form that makes a constant securing of everyone’s consent impossible. By being aware of the informant and possible implications, I constantly attempted to avoid harming or taking advantage of informants. I am convinced that no part of the fieldwork led to harmful events, but I will never know and will never be able to completely comprehend every situation. Therefore I also have to trust that the informants would have said no if they became aware of unwanted possible implications.

31

I have made the mothers anonymous in the empirical material as per prior agreement.

98

Discussion For whom did I do this? It is neither responsible nor ethically justifiable to be naïve and believe that the time I spent in the clinic was beneficial for the patients or the clinic. Along those lines, it is a simplification to believe that the interviews were of therapeutic benefit for the mothers I interviewed. The time spent in the clinic and with my informants was due to an initial wish o conduct a study within this field and was hence initiated for the benefit of my study. In addition to achieving these goals, perhaps either some people or processes can benefit from my fieldwork or the subsequent analyses. This has of course been a hope of mine, yet such benefits cannot be certain from the beginning. I tried hard to help where I could while in the clinic. I invested myself in the interviews and was as empathetic to the problems of the informants as possible. Yet these factors do not change the fact that this study was initially undertaken with another purpose. 9.4

Public health relevancy: drawing perspectives

Within the demographic literature on fertility in Palestine, the concept of political fertility has been hypothesised. With this study I have been able to show that such a concept does play a crucial part in fertility on the ground, and moreover, showed how this abstract concept is enacted by mothers, health providers and policy planners. This thesis thus contributes to the knowledge and understandings of what is at stake for fertility in Palestine. It thereby gives a voice to mothers in Palestine to be heard and to be taken into consideration. By showing the links between the perceptions of importance within the policy and clinical spheres and within the social worlds of the mothers, the mothers take a position from which they can speak. Fertility is not just a concept that is done on paper, as this study shows. On the ground, mothers are actively using family planning methods according to their desire. Having children is important, crucial and highly affected by the political situation of an occupied people, rendering control over numbers of children undesirable, while spacing in between children is considered acceptable. For health providers and policy planners these findings can be used as a contribution towards improving services and policies in order to ensure access and availability of family planning services as well as health of the Palestinians. These findings can also be relevant when assessing the impact of the conflict on a micro-level from a perspective of health and health behaviour that is seldom part of studies of conflict. 99

Beyond Numbers: Political Fertility in Palestine Also in a wider perspective this study is of value. The nuances this study brings to classic demographic understandings and the developmental discourse can be of relevance in others settings, and not merely those of conflict. This study points at the impact of fertility decision-making as a complexity of individual decisions framed by local political situation. The study is evidence that the concept of health is not merely what shapes health perceptions, health seeking behaviour and health politics. Such concepts are to a wide extent shaped by political and social considerations that we must be able to understand if we aim to ensure the health of a people. The part of the developmental sphere that pushes for family planning in accordance with human rights must give weight and importance to the factors that lie outside health considerations or empowerment achievements, in order to understand what is at stake on the level of the perceptions of having children. The political situation plays a central role in what health services are provided and what health services are used.

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Conclusion

10 Conclusion This thesis presents an ethnographic study of fertility, a core demographic concept at the heart of public health. It yields insights that expand and substantiate what we already know of fertility in Palestine. Fertility rates have declined in Palestine in recent decades and the current rate is 3.9 children per woman amongst refugees in the West Bank (UNRWA, 2011b). Compared to what is known from demography on socioeconomic trends, proximate variables and the health status of the population, this figure is remarkably high. The gap is ascribed to one abstract notion - political fertility – but what does this notion entail? With the choice of an ethnographic inquiry into the perceptions of fertility amongst refugee mothers, health providers, and policy planners, this study enables a thorough understanding of fertility in Palestine. It gives insights into how such a notion is a part of everyday life and decisions to have children. The methodology allows for an unfolding and challenging of a concept stemming from demographic science, thus bringing the interdisciplinary nature of public health science into play. In Kalandia refugee camp in the West Bank, family planning services are provided at the UNRWA health clinic and Palestinian refugee women utilise these services. My empirical material shows that having children is central to maintaining a people and a nation for the woman, the extended family, and the policy sphere. Fertility, to have children, is political in Kalandia camp. Mothers ascribe political aspects to their reasons to have children as well as to their perceptions of fecundity. Provision of family planning services contains elements of biopolitics as the provision becomes part of creating a politically fertile Palestinian. A calculus of how many children is performed with notions of kin, conflict and the nation, but without reference to numbers as such. A decrease of the fertility rate below four children is unlikely, at least until the perceptions upon which these calculations are built change. An important finding that expands the current knowledge base of the field of fertility in Palestine is that of the implications of infertility, a topic that does not figure in the literature. Infertility is conceived of as devastating by the women of Kalandia camp, although this is at odds with the role it plays on the agendas of health providers and at the policy level. Political fertility is most commonly understood as entailing more children and higher fertility rates, yet my material challenges such a correlation. Families with little political awareness or no self-perception of being part of a national 101

Beyond Numbers: Political Fertility in Palestine struggle are also having many children, while families afflicted by the conflict in the most gravest possible way (death of sons or imprisonments) are having fewer children, in part as a result of the economical hardship induced by the conflict, and as a political choice by being scared of losing children. To the field of demography, my findings bring a nuance to the hypotheses of what plays significant roles in the decision to have children. In the case of Palestine, it seems that the fear of losing an adolescent child to either death or imprisonment due to the conflict is one major concern of mothers. Remembering the point of discursive phrases in contexts of conflict and war, the political presence must be questioned as to whether the degree of politics is this potent at all times, or whether it perhaps at times takes the form of phrases of positioning, trivialities, or at times a play set up to please the expectations of an outside world or create a collective. This thinking helps us to understand the apparent contrast of ideological representations of having children as merely a political action and the concurrent actual anxiety and care the mothers show for their children: these are not mutually exclusive, but intertwined. The majority of refugee women, health providers and policy planners perceive the recent decrease in fertility as a sign of development, and family planning as a sign of modernity. On the other hand, there are also some arguing against decreasing fertility rates with arguments of traditionalism and nationalism. The positions are clearly conflicting. Conducting family planning services is thus highly politically sensitive, and policy planners refrain from talking about numbers. Family planning services are therefore sought to be ascribed the meaning of being a question of timing of children rather than a question of controlling the numbers of children. Hereby a possibility of understanding family planning use and provision as pertaining to health concerns is offered, rendering family planning possible in a context of political fertility with numbers being so political. In demographic academia and in the health services providing family planning, we must be aware of the political aspect of fertility. From a public health perspective, as well as developmental, human rights and gender perspectives, decreasing fertility and the utilisation of family planning methods can be seen as positive for the health status, empowerment and possibilities of women. Yet, we must remember that fertility is more than just the number of children: the political importance of future Palestinians is a factor that cannot be overlooked. This acknowledgement gives useful 102

Conclusion aspects (of imposing values) to consider when introducing new interventions or improving the family planning programs already in place. In its own way too, the political understanding of fertility also stresses the importance of a durable solution to the conflict in order to take the pressure of fertility as a battleground. Fertility in Palestine is beyond numbers.

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Beyond Numbers: Political Fertility in Palestine

Appendix I: Collection of empirical data Date 06.09

10.09

Type of data Pretest of womeninterview guide Background Interview Policy Interview Interview

10.09

Interview

11.09 12.09

Policy Interview Interview

14., 15., 19.-22., 24. (7 days)

Observations from clinic

08.09

19.09

Brochures and photos of posters Informal “interviews” with staff Interview Interview

21.09

Interview

29.09

Interview Interview Interview Interview Interview Interview Interview

03.10 10.10 13.10

Informant Maha (prev. colleague)

Duration

Dr. Abu-Rmeileh, ICPH

62 min

Notes Notes

MoP 92 min Woman A 42 min (39, 4 children) Woman B 56 min (36, 5 children) MoH 60 min Couple C 33 min (Women: 17, Man: 29, 1 child) Organization of services, physical setting, interactions

Transcription Transcription

On Family Planning

Transcription

On services, on FP, on women’s use of FP Staff Nurse in ANC Women D 45 min (34, 4 children) Senior Health Officer of 35 min Kalandia UNRWA Clinic Women E 64 min Women F 44 min Women G 84 min Women H 47 min UNFPA UNRWA Dr. Khammash UNRWA Statistics

Notes

Transcription Transcription Transcription Notes

Notes Transcription Transcription Transcription Transcription Transcription Transcription Notes Notes Notes

NOTE: All empirical material (audio files, transcription, field notes, brochures, photos) can be obtained from the study secretariat (as arranged with the study secretariat Susanne Hannecke).

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Appendix II: Participant Observation guide

Appendix II: Participant Observation guide Observations at clinic Introduction    

Thank you for participating “I wish to learn about having a family and children in Palestine. I will ask you questions about the services you can get here when you have children ...” I will just observe the services Consent orally: you will remain anonymous, you can stop at any point

Be aware of:          

Posters on the wall Audio-visual privacy Opening hours Encourage male involvement? Family relations Fees for services? Expenses in relation to services? Out-of-pocket costs? Special access to family planning Information about the choices What services are provided/recommended?

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Appendix III: Collection of Interview Guides Interview guide – women  

 

Thank you for participating “I wish to learn about having a family and children in Palestine. I will ask you questions about having a family and about the services you can get here when you have children ...” Consent orally: You can stop at any point and I will not mention your name anywhere Okay that I record this so I can remember?

Demography / Family 

(Name), age + Tell me your story:

Where are you from? Parents? Siblings? How come you and your family are living here? How did you meet your husband? When did you marry? Did you move here after that? How many children do you have? Tell me what it is like to have a family in the West Bank? Having children    

How many children would you like? Why this number? Why not more? Why not less? What if conditions (economics fx) changed?



Is it important for you to have children? Why? What do you see as the most important about having children? What is good/bad about having children? What do you want for their future? What do you see them as when they grow up? Why do you think your husband wanted children? Your mother? Your mother-in-law? What do people say when you tell them how many children you want?

   106

Tell me about the time you had your first child? (probe: why then? Right time how?...) Do you want to have more children? What would you consider before having another child? What is important for you in the decision? (value)?

Appendix III: Collection of Interview Guides  

How many children do you want for your daughters? What do you think about the decline in numbers of children women are having?

Services   

What services did you use when you were at the UNRWA clinic when we met you? What do you think of the services? What do they say about having more children? What would they say if you were to have your Xth child?

Landing the interview : input 

“We are near the end” + Thank you for your time and

Is there anything you would like to add? To ask me?

 Okay to contact if additional questions? Interview guide – Health staff  

 

Thank you for participating “I wish to learn about having a family and children in Palestine. I will ask you questions about having a family in Palestine and about the services you can get here when you have children ...” Consent form – you can stop at any point and I will not mention your name and organisation Okay that I record this so I can remember?

Demography 

Name, age, education, job

Reproductive Health Services     

What services do you provide at the clinic? Which are you involved in? Which are related to the fertility of women? What questions do women come with? Do all women attend the clinic (for prenatal care)? In your understanding: What influences the decision to have a child among the women you see?

Health Policies 

What are the recommendations for young women in relation to having children? 107

Beyond Numbers: Political Fertility in Palestine

 

o (probe: age, spacing, family planning methods, number of children) Is there a written policy of the clinic? How do you share the policy (trainings, discussions)? How do your policies here relate to the ones of the MoH? (probe: similar, take from them, try to influence them)

(perhaps at another time/setting – about personal matters – OK?) Having children         

Tell me about your family (husband, children + parents, siblings) How many children do you prefer to have? Do you think having children is important? What makes it important? What do people say when you tell them how many children you want? What do you think your husband’s main reason for wanting more children was? Your mothers? Your mother-in-law? Let’s say that you daughter/cousin tells you she is pregnant with her 5th/Xth child: What do you tell her? What do you think about the decline in numbers of children women are having? Why do you think women are having fewer children now? What was different from your mother’s generations thinking about having children?

Landing the interview   

“We are near the end” + Thank you for your time and input Is there anything you would like to ask me? Is there anything I should have asked you? (What did you expect? Why did you participate?)

 Okay to contact if additional questions?

Interview guide - MoH Introduction  

 

Thank you for participating “I wish to learn about having a family and children in Palestine. I will ask you questions about the health policies and the services you can get here when you have children ...” Consent form – you can stop at any point Okay that I record this so I can remember?

Services and beneficiaries 108

Appendix III: Collection of Interview Guides  

  

What are the role of the Ministry of Health in relation to policies (on fertility)? What are the services you aim at providing to women in relation to reproductive health? o (In Primary and Secondary Care) What services are in place? Are there any differences for refugees and non-refugees in health services? How do you work with UNRWA in relation to reproductive health? Common guidelines? Differences in policies or in services?

In practice   

What do the MoH consider to be the ideal number of children for a woman to have? What are the recommendations for women? Let’s say that a young woman is expecting her 5th/Xth child and approach the MoH health services: What should the health professional tell her?

Policy   

What are the policies for women in the reproductive age? For pregnant women? For new mothers? What are the main priorities for family planning in the West Bank? For a policy on family planning what do you value the most? Are there agencies that take a different view on fertility?

Landing the interview (“near the end”)    

Thank you for your time and input Is there anything you would like to ask me? Is there anything I should have asked you? (What did you expect? Why did you wish to participate?) Okay to contact if additional questions?

Interview guide – MoP Introduction  

 

Thank you for participating “I wish to learn about having a family and children in Palestine. I will ask you questions about the health policies and the services you can get here when you have children ...” Consent form – you can stop at any point Okay that I record this so I can remember? 109

Beyond Numbers: Political Fertility in Palestine Ministerial Set-up   

What is the role of the Ministry of Planning? How are you involved in the policies of population? Can you tell me the story of the Population Committee? o (why initiated, what started process, whom?)

Services and beneficiaries  

  

What is the position of the PA on fertility? On reproductive health? What is the objective and goal? What are the services you aim at providing to women in relation to reproductive health? o (In Primary and Secondary Care) What services are in place? Are there any differences for refugees and non-refugees in health services? How do you work with UNRWA in relation to reproductive health? Common guidelines? Differences in policies or in services?

In practice   

What do the MoH consider to be the ideal number of children for a woman to have? What are the recommendations for women? Let’s say that a young woman is expecting her 5th/Xth child and approach the MoH health services: What should the health professional tell her?

Policy   

What are the policies for women in the reproductive age? For pregnant women? For new mothers? What are the main priorities for family planning in the West Bank? For a policy on family planning what do you value the most? Are there agencies that take a different view on fertility?

Landing the interview (“near the end”)    

110

Thank you for your time and input Is there anything you would like to ask me? Is there anything I should have asked you? (What did you expect? Why did you wish to participate?) Okay to contact if additional questions?

Appendix III: Collection of Interview Guides

Interview of UNRWA Health Clinic Director, West Bank    

 

    

Data available? Set up meeting In what way does Kalandia differ/resemble other camps? Community, health care, female employment? Tell me about the work of UNRWA in the West Bank related to fertility? To family planning? o Objective, goal, organizational set-up, services o Relation to UNFPA Does UNRWA have a written policy on family planning? How do you share the policy (trainings, discussions)? Are there courses for the staff? How do you work with PA (MoH) in relation to reproductive health? Common guidelines/Differences in policies/services How do your policies here relate to the ones of the MoH? (probe: similar, take from them, try to influence them) What are the challenges of working with Family Planning? How has this work changed in the last decades? What are the main priorities for family planning services in the next years?

In practice: 



What are the recommendations for young women in relation to having children? o (age, spacing, family planning methods, number of children) What do the staff consider to be an ideal number of children?

Interview of UNFPA, Dr. Ali Shaar, Health Officer   

 

Data available? Set up meeting In what way does Kalandia differ/resemble other camps? Community, health care, female employment? Tell me about the work of UNRWA in the West Bank related to fertility? To family planning? o Objective, goal, organizational set-up, services o Relation to UNFPA Does UNRWA have a written policy on family planning? How do you share the policy (trainings, discussions)? Are there courses for the staff?

111

Beyond Numbers: Political Fertility in Palestine     

How do you work with PA (MoH) in relation to reproductive health? Common guidelines/Differences in policies/services How do your policies here relate to the ones of the MoH? (probe: similar, take from them, try to influence them) What are the challenges of working with Family Planning? How has this work changed in the last decades? What are the main priorities for family planning services in the next years?

In practice: 



What are the recommendations for young women in relation to having children? o (age, spacing, family planning methods, number of children) What do the staff consider to be an ideal number of children?

Background Interview at ICPH – Dr. Niveen Introduction to thesis 





Introduction o Fertility: Public/private sphere; number of interests; decline but still high fertility; refugee situation; policies and practice Problem Statement o How are clinical encounters regarding reproductive health being conducted at the local clinic for refugee women in Qalandiya camp? o How do these clinical encounters resound in fertility understandings among the women? Methodology: observations and interviews (+policies)

Current knowledge base The fertility rates have declined, yet they remain high compared to the rest of the world:    

What are the hypotheses of the fertility rates in the West Bank? Setting: what is important for fertility here? How is the situation in comparison? Differences within Palestine: Gaza/WB – within WB – refugee/non-refugee?



What is the health policy of the PA/MoH? Of UNRWA? Of NGOs? Clashes? Who are the stakeholders of the policies? What are the public services that influence fertility? o Are there incentives from PA?

 

112

Appendix III: Collection of Interview Guides o Are there barriers? Research at ICPH  

Current research in reproductive health? Any studies of governing through health policies?

Materials   

Key materials? Anything in Arabic? Library?

Landing the interview (“near the end”)  

Thank you for your time and input Is there anything you would like to ask me? Is there anything I should have asked you?  Okay to contact if additional questions?

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Beyond Numbers: Political Fertility in Palestine

Appendix IV: Condensation of empirical material Quotes/Notes on post-its Case with one son Friends suffering from difficulties Health problem can be reason for few children Longing for babies, children Passion for babies (as oppose to Western world) You must want children Efforts for 2nd child (IVF: expenses, energy) Becoming a mother, natural, a circle of life, an identity Role as a mother Helping in old age Muslim/Religion + Human Race/Natural God/religion + National Strength

Material E B A A, D, F A

Category

Theme

Infertility

Having children (I)

Naturalness of motherhood

E E F A A,B C D

Value of children Mothers of a nation Structural expectations of motherhood

Women are filed by reproductive status Filing system at clinic allows for up to 12 children Arafat paid IVFs Shopping for IVF doctors

OBS OBS

Other patients barge in ANC room for files Midwife/nurses locks door Rigth of patients that we ensure privacy

OBS OBS OBS/I nterv. OBS

Privacy in clinic

A

Role of relatives/grandmother

Hand-out of FP products done in ANC, not pharmacy counter decision of numbers

E E

Political fertility with fewer children Perceptions of risk of death of close family members Childhood in camp: play inside Not know whether your son returns Economical situation, expenses Health Avoiding repetition of his childhood in poverty FP is highly used Openly says which FP they use Openly talk about FP use (in front of husband, family, in-laws) Palestinian lifes: “difficult, the siege makes the children hate their lifes” Financial impact of martyr/imprisoned son Martyr families special status Young son wants to become martyr Passion for babies (as oppose to Western world) Day of UN State bid = fewer patients in clinic

D, G B, E, G

Donors funds FP, not infertility

MoH

114

F B A, C A C OBS OBS A, B, C D G OBS D A OBS

Health seeking behavior

Non-political determinants of having children Family planning in practice Conflict’s impact on motherhood

International politics on micro-level Politicising

Being Palestinian (II)

Appendix IV: Condensation of empirical material Speaking of WB/Gaza differences FP not a PA priority, UNFPA funded Have written guidelines Talk about FP programmes as any other program: not experiences as as controversial Fertility rate decline is talked about as positive “people provoked to have more children” X sons and X daughters Families prefer boys Sister&Sister + Brother&Brother Siblings in same-sex teams Brothers & Sisters in teams ”must have 1 son” ”Jews kill children”, no. of martyrs => 2 sons is best Boy preference/Sex composition “Only 4 children; ya’haram” – good thing others have more ”2-3 children are not consider problem” “For Palestine 2-4 not good, might loose some” Good with 4 “We PLAN for 4 children” Not responsible for number (number is not important) “not planned numbers, never thought of how many” – Gods will Not her decision how many: Fate, fate, fate Happy with two sons but then pregnant: accepts what God gives FP information after 1st birth (0 children not thought of as option) FP done in relation to MCH Use of FP: “Women wants to rest, finish what she wants” NOT speak about FP! Not for decrease, not limiting, not fertility: It is for health for spacing, approved by Quran Sensitive political area “Why should we decline in fertility? Written policy on population: “No leave it. We have on-ground services and in-direct policies” “Palestine suffers from Arafats statement that demography is political” “Society is not ready to take policy”

MoH

PA’s work with fertility/FP UNRW UN’s work with FP A UNFPA UNRW A UNPolitical fertility RWA seen as explanatory for high TFR F “2+2”/ sons and MoH teams A D F A OBS B D B A C G

Numbers (III)

Societal expectations to no.’s

Planning the number

D F B OBS MoH MoH

FP is thought of as spacing

MoH

Politicising of fertility

MoH MoP MoP

PA’s work with fertility/FP

MoP MoP

A-H: The interviews with women; OBS: The observations within the UNRWA Health Clinic in Kalandia camp; UNRWA, UNFPA, MoH, MoP: The interviews with policy planners respectively.

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Beyond Numbers: Political Fertility in Palestine

Appendix V: Consent Form for UNRWA Kalandia Clinic Consent Form – poster (A4): University of Copenhagen, Denmark

Ramallah, September 2011

‫موافقة‬ ‫ سوف تكون‬،‫ وهي طالبة في الصحة العامة في جامعة كوبنهاغن‬،‫ ليف هانسون‬،1122 ‫في سبتمبر‬ .‫متواجدة في عيادة األونروا في قلنديا عند التوصل إلى اتفاق مع األونروا‬ ‫ليف هانسون متواجدة إلجراء بحوث على وجود األطفال في الضفة الغربية وخدمات الصحة اإلنجابية في‬ ‫ لن تسأل على‬.‫ هانسون سوف تراقب وتطرح بعض األسئلة بعد موافقة المرضى‬.‫عيادة األونروا في قلنديا‬ ‫ يمكن من المشاركين في أي لحظة ودون أي تفسير‬،‫االسماء و سوف يكون جميع المشاركين مجهولين الهوية‬ .‫إيقاف المقابلة و استعادة الوقة بالمعلومات المعطاة‬

,‫مع الشكر‬ ‫ليف هانسون‬

Consent In September 2011, Liv Hansson, a Public Health student at the University of Copenhagen, will be present in the Kalandia UNRWA clinic as per agreement with UNRWA. Liv Hansson is here to do research on having children in the West Bank and the reproductive health services in the Kalandia UNRWA clinic. She Hansson will observe and ask some patients questions if they give their consent. All participants will be anonymous and can at any moment and without explanation stop the interview or take back the information given. Thank you, Liv Hansson

116

Appendix V: Consent Form for UNRWA Kalandia Clinic

Consent Form – handout:

‫موافقة‬ ‫ سوف تكون متواجدة‬،‫ وهي طالبة في الصحة العامة في جامعة كوبنهاغن‬،‫ ليف هانسون‬،1122 ‫في سبتمبر‬ .‫في عيادة األونروا في قلنديا عند التوصل إلى اتفاق مع األونروا‬ ‫ليف هانسون متواجدة إلجراء بحوث على وجود األطفال في الضفة الغربية وخدمات الصحة اإلنجابية في‬ ‫ لن تسأل على‬.‫ هانسون سوف تراقب وتطرح بعض األسئلة بعد موافقة المرضى‬.‫عيادة األونروا في قلنديا‬ ‫ يمكن من المشاركين في أي لحظة ودون أي تفسير‬،‫االسماء و سوف يكون جميع المشاركين مجهولين الهوية‬ .‫إيقاف المقابلة و استعادة الوقة بالمعلومات المعطاة‬

,‫مع الشكر‬ ‫ليف هانسون‬

Consent In September 2011, Liv Hansson, a Public Health student at the University of Copenhagen, will be present in the Kalandia UNRWA clinic as per agreement with UNRWA. Liv Hansson is here to do research on having children in the West Bank and the reproductive health services in the Kalandia UNRWA clinic. She Hansson will observe and ask some patients questions if they give their consent. All participants will be anonymous and can at any moment and without explanation stop the interview or take back the information given. Thank you, Liv Hansson

117

Beyond Numbers: Political Fertility in Palestine

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