Palestinian women's pregnancy intentions: Analysis and critique of the Demographic and Health Survey 2004
Introduction
The inclusion of a question on pregnancy intentions (intended, mistimed or unwanted) has gradually become part of routine worldwide surveys [1], [2], [3], [4] including the Demographic and Health Surveys (DHS). However, the meaning of pregnancy intentions and the assumed stability of intendedness responses are increasingly being questioned, calling for rethinking the concept and the need for developing new measures that would provide more relevant information for policy and program planning purposes [5]. A key issue for consideration is the validity of retrospective assessments of pregnancy intentions, where in DHS surveys, women are asked if they desired to be pregnant at the time of conception, or desired to wait or did not want the pregnancy at all, with conception having occurred up to 3 or even 5 years preceding the survey response in some versions. The question is designed to reveal women's feelings and preconception attitudes towards pregnancy [6]. Yet, feelings and attitudes can change substantially during pregnancy and afterwards, and are subject to rationalization (or perhaps justification) after the fact, raising questions as to what is being measured, and hence, the relevance of responses to policy making and planning.
Moreover, the literature on the subject has generally focused on unmet needs for contraception, abortion services, and family planning education [7], [8], [9] suggesting that simple access to services and education can bring about a resolution of the problem. Although access to services, education and counseling are of course important, this remains a microscopic and simplistic view of women's realities which may lead to blaming the victim, as access to services and education do not necessarily translate into the reduction of the risk of new unplanned pregnancies [10]. Nor do they mean that the freedom to choose and act on the choice made, or that the basic human right of couples and individuals to achieve the desired family size responsibly and freely [11] is realized through contraceptive and abortion service provision alone. This is because women's reproductive behavior is socially constructed, where the exercise of choice in reproductive intentions is constrained by women's broader contexts and the realities of their social worlds. Clearly, more fundamental and broader level issues than access to services need to also be addressed, including changes in the structures of domination over women's freedoms of various sorts, including reproductive freedoms and rights. In the Middle East and North Africa, law, social practices, traditions, religious and cultural constructs all interact to seriously limit women's abilities to realize their reproductive intentions [12] and take charge of their lives, as is the case elsewhere given that gender discrimination is universal, although expressed in modified forms in line with context.
Likewise, unmet need as a concept cannot be simply construed as unmet need for contraception and abortion [13]. The concept also includes the need of couples for fertility care, a basic human right that is often neglected in the translation of the concept into policies and programs, or considered a minor problem [14].1
This is particularly relevant to couples of the developing world where the focus is often on coercive population control, instead of on the underlying factors for excessive population growth [15]. In the case of the OPT, the rapid population growth and high fertility levels are unfortunately usually highlighted as either a threat to Israelis, or as a weapon of resistance by Palestinians [16]. The considerable differences in fertility levels between the West Bank and Gaza Strip are also a focus of research attention, and routine comparative assessments of these regional differences [17]. The threat versus weapon views, however, do not take into consideration the contextual aspects that determine high fertility levels especially in the Gaza Strip, and the lack of state benefits in old age, where children function in lieu of social security, among other considerations [18].
In working to locate some of the correlates of unintended pregnancies, the literature seems to focus on behavioral determinants, such as the ineffective use or non-use of contraceptives [19], [20] or the time of initiation of prenatal care [21], [22] both possibly associated with access to and quality of services; selected demographic and socio-economic indicators, such as maternal age, education, urban/rural residence and region [23], [24] and birth outcomes, such as the infant's birth weight [8], [22]. In this article, which is part of a larger investigation of what Palestinian women want for reproductive health care, we work with what is available: a DHS2004 data set obtained by using the customary DHS instrument used worldwide. We make use of the available data set to complete an analysis of Palestinian women's pregnancy intentions, which has not been attempted previously. In addition to including behavioral, socio-economic and infant related outcome indicators in our analysis, we also investigate the degree to which intendedness reports are associated with the process/experience women undergo during pregnancy and childbirth, with biomedical prenatal and post natal complications and type of delivery she underwent as measures of this process (limited by what is available in the data set). We compare the responses of women from the Occupied Palestinian Territory (OPT) with those found in the international literature, working to discern patterns of commonalities and differences. In the process, we pay special attention to the conceptual and methodological gaps revealed by the analysis of available Palestinian data sets, i.e. standard DHS’ based on the worldwide used instrument, in the hope that this will assist in strengthening the argument for the need to continue modifying DHS surveys to include a broader perspective of women's health, needs, constraints and realities. Indeed, the Palestinian Central Bureau of Statistics has already taken a step in this direction by including a special section on single women's health in the DHS2004, usually absent from the standard instrument which focuses on maternal and child health and family planning, as if suggesting that women's health and reproductive health concerns pertain to her being a biological producer only. In the end, it is hoped that the DHS will eventually be transformed to reflect its true name, by including demographic and health indicators on all sectors of the population, and not just women of childbearing age and their children.
Section snippets
Methods
The PCBS-DHS2004 data set included 5799 households: 3746 on the West Bank and 2053 in the Gaza Strip. The list of all Palestinian households was constructed by updating identification variables from the data collected in the 1997 Population Census. The Master sample was used as the sample frame for the DHS2004. The target population consisted of all Palestinian families that usually reside in the OPT. The sample that was drawn is representative of all of the Palestinian population. The survey
Results
Our sample consisted of ever-married non-pregnant women 15–49 years old. Of the total, 74.5% were under the age of 35. Thirteen percent reported having had more than a high school education. Fifty-nine percent resided in the West Bank and 41% in the Gaza Strip. Fifty-five percent lived in urban, 28% in rural locales and 17% in refugee camps housing those displaced in the 1948 and 1967 Arab-Israeli wars.
Of the total, 64% reported that they desired their last pregnancy, 16.7% reported that they
Discussion
The results of this analysis reveal commonalities and differences with the international literature on pregnancy intentions. Older women (35+) were found to be significantly more likely to not desire the pregnancy at all, while younger women (<35) were more likely to have desired to wait (mistimed), findings that are comparable to what has been repeatedly demonstrated in the literature. In line with well established findings [25] there was a strong association between the total number of
Conclusion
From our original intention of working to understand what women want for reproductive health care, our analysis offers us fewer indications of women's needs and constraints than indications of the conceptual and methodological gaps contained in the DHS survey instrument currently used in the OPT, seen from a public health policy perspective. These surveys were originally initiated in the 1980s, in order to obtain worldwide demographic and family planning data, with the objective of providing
Competing interests
None declared.
What is already known on this subject
Pregnancy intention research is often focused on unmet needs for contraception, education and counseling as methods of reducing the risk of unplanned pregnancies.
What this paper adds
In addition to including behavioral, socio-economic and infant related outcome indicators in our analysis of pregnancy intentions, we also investigate the degree to which intendedness reports are associated with the process/experience women undergo during pregnancy and childbirth.
Policy implications
The paper argues for a continued modification of the DHS surveys to include a broader perspective of women's health and needs from a public health policy perspective. We also call for the inclusion of additional social measures that can identify further some of the contextual factors that influence pregnancy intentions.
Conflict of interest
None declared.
Acknowledgements
We would like to thank the Palestinian Central Bureau of Statistic's president and staff for their cooperation and willingness to include additional questions to what is contained in customary Demographic and Health Surveys. We would also like to thank the UNFPA, Jerusalem office, for the partial financial support it provided the authors to complete this study. Rita Giacaman would like to thank the Faculty of Health Sciences at the American University of Beirut, Lebanon, for offering her a
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