The Unique Landscape of Abortion Law and Access in the Occupied Palestinian Territories

Sarrah Shahawy

Abstract

Abortion remains a highly debated topic in women’s health in the Middle East and specifically in the occupied Palestinian territories (OPT), where it is illegal in most cases. Abortion access is challenging and complex due to laws, hospital policies, and the fragmented nature of the OPT and its health care system. This paper explores several barriers to accessing safe abortion care in the OPT, many of which are unique to living under occupation and at the interface of multiple legal systems. Legal restrictions on the provision of abortion services and the negative impact of the occupation on freedom of travel create a complex landscape in which Palestinian women are forced to navigate multiple legal and medical systems when seeking abortion services.

Introduction

Much of the limited data on abortion in Muslim-majority countries excludes the occupied Palestinian territories (OPT), which include the West Bank, East Jerusalem, and the Gaza Strip. The OPT is often excluded in this data because the West Bank and Gaza Strip are not currently considered sovereign and there are significant data limitations in assessing the Palestinian population living under occupation.[1] Palestinian women are subject to geopolitical challenges distinct from women in other Muslim-majority countries due to the political situation in the OPT. As a result of the ongoing military occupation that began in 1967, the movement of Palestinians within the occupied territories is constantly restricted.[2] This geopolitical context poses unique challenges to health care delivery and access in general, including reproductive health services.[3] The OPT has a politically imposed fragmented landscape of health care providers, and hospitals are a mix of governmental, private, and nonprofit.[4] The obstacles to a sustainable, cohesive health care system contribute to poor overall health in the OPT, especially for women.[5] Although family planning services have long been available through facilities run by the United Nations Relief and Works Agency, the government, and nongovernmental organizations, unintended pregnancy is common.[6] A 2007 study conducted by Ayesha AlRifai for the Palestinian Family Planning and Protection Association (PFPPA) found that 40% of 333 women surveyed in West Bank refugee camps had undergone an abortion, although the study also stated that some of those women said their abortions were spontaneous and involuntary.[7] Thus, the delivery of reproductive health services is important in this population. Certain services, such as access to maternity facilities by women in labor, have been affected by the mobility restrictions imposed by the occupation, leading to decreased access to post-partum and gynecologic care and an increasing number of home deliveries and deliveries at military checkpoints.[8] There is also a shortage of obstetricians and gynecologists in the West Bank and Gaza, with these physicians being poorly distributed and concentrated in the private sector, compromising the quality of care in government institutions.[9] One qualitative study conducted in 2002 by Marleen Bosmans and colleagues found that access to sexual and reproductive health services had become significantly restricted for both refugees and non-refugees in the OPT.[10] They also found that the worsening political situation and humanitarian crisis had a negative impact on Palestinian women’s health and rights by lowering the priority and funding of many sexual and reproductive health policies and programs. This is important to consider, especially in light of the fact that Palestine has ratified the Convention on the Elimination of All Forms of Discrimination against Women.[11]

Palestinian women are vulnerable to the realities of occupation, as well as historically patriarchal social and legal structures. In this paper, I examine multiple barriers to accessing safe abortion care in the OPT, many of which are unique to living under occupation and at the interface of multiple legal systems. The legal restrictions on the provision of abortion services and the negative impact of the occupation on freedom of travel creates a complex landscape in which Palestinian women must navigate multiple legal and medical systems when seeking these services. I show how these barriers are interrelated in the context of occupation and contribute to a uniquely challenging environment for obtaining safe abortions. By reviewing the limited literature on this topic and interpreting a series of cross-sectional qualitative interviews with Palestinian women, I aim to illustrate the lived way in which Palestinian women perceive how these barriers affect abortion access in the OPT.

Abortion law in the OPT

It is in the unique and complex geopolitical context of the occupation that abortion for Palestinian women must be considered. Like other countries in the Middle East, the social context, legal mechanisms, religious interpretations, and cultural factors within the OPT shape much of the conversation around induced abortion. In the OPT, abortion is criminalized under articles 321–325 of the Jordanian Penal Code of 1960, which is derived from colonial French and Ottoman laws.[12] According to this law, penalties apply to the woman seeking the abortion and all individuals and health care professionals who assist her in terminating the pregnancy.[13] Article 8 of Palestinian Public Health Law No. 20, which was passed in 2004, states that in the West Bank and Gaza, abortion is prohibited by any means unless necessary to save the pregnant woman’s life, as proven by the testimony of two specialist physicians.[14] Written approval from the pregnant woman and her husband or guardian must also be provided, and these records are kept for a minimum of 10 years. The law reflects and reinforces the sociopolitical opinion in which induced abortion should be restricted to situations in which the pregnant woman’s life is in danger, which is indeed the only situation in which an abortion can currently be legally obtained in the West Bank and Gaza.[15]

Our qualitative study: Voices of Palestinian women

In 2014, my colleague Megan Diamond and I conducted a qualitative study consisting of individual interviews with 60 Palestinian women on their perceptions of the religious implications, social consequences, and accessibility of induced abortion in the OPT.[16] The recruitment and interviews took place over four weeks in December 2014 at Al-Makassed Islamic Charitable Hospital in East Jerusalem, which is uniquely situated in that it is the premier tertiary care hospital serving Palestinians living throughout the OPT in Jerusalem, the West Bank, and Gaza, allowing for a more diverse sample. We used convenience sampling to recruit participants. Inclusion criteria included non-pregnant Palestinian women over the age of 18 living in Jerusalem, the West Bank, or Gaza. Eligible participants included patients, female companions of patients, and hospital staff. The 60 women interviewed ranged in age from 18 to 70 years. The majority of participants were Muslim, married, and urban dwellers; had a high school education or less; and had at least three children. I conducted the interviews in Arabic, and both of us carried out thematic analysis of the interviews. Our study was approved by the Harvard Medical School Institutional Review Board (approval no. IRB14-4006) and the institutional review board at Al-Quds University Medical School in Palestine. Some of the data and findings from our study were published in Culture, Health and Sexuality in 2017. 

Limited access to abortion in the OPT

Our study found that the unique legal and medical context of the OPT affected Palestinian women’s access to abortion services.[17] Access to induced abortion was generally identified as difficult and complex due to laws, hospital policies, and the fragmented nature of the OPT and its health care system. When asked about the law, women were unequivocal in their answers. As one lawyer from Gaza explained in an interview, “Abortion is illegal in all cases, even in extramarital pregnancy. It is only allowed for health reasons for the mother or for fetal anomalies. The law doesn’t allow for anything else, even for unmarried women or rape. They don’t do it.” Thus, difficulty in access is often contingent on the reason a woman is seeking an abortion. When asked whether abortion was easy to access and whether it was legal, one woman explained:

I know that no doctor will allow me to abort without a reason—it’s not easily found here with us, unless it’s in a private way or through someone important you know. But still it’s not common. … Everything is in secret. If it’s a medical issue for the woman, then it’s fine. But not for other reasons.

While women were firm in their general understanding of the abortion law, they called into question its application given the complexity of law while under occupation. As one woman exclaimed, “There is no nation. There is no law. Who is going to judge or punish? They won’t get involved unless there’s a problem like rape. If we had a nation and a government, then maybe there would be a law.” Thus, the paralyzing legal structure in the OPT and the daunting question of statehood and sovereignty not only prevent a true understanding of the scope of the law but also limit reforms to existing laws. Reflecting this discordance, one woman living in the West Bank said, “There is no legal punishment [for the woman]. There is no law in the country. But they’ll punish the hospital or the doctor.” However, while it may not be universally applied in this way, the 1960 Penal Code applies penalties both to the woman seeking an illegal abortion and to the health care personnel providing her with one. Therefore, the OPT’s abortion law understandably affects hospital policies and serves as a significant barrier to abortion access among Palestinian women.

Reflective of the legal context, Palestinian hospital policies are equally restrictive with regard to abortion. One of the physicians we interviewed confirmed this:

We’ve had a lot of cases who come [to Al-Makassed Hospital to abort] for nonmedical reasons and unwanted pregnancies, or unplanned. And we tell them we don’t do them and refer them somewhere else. [Interviewer: Do you tell them where they can go?] No no, we just tell them to go elsewhere.

Thus, laws implicating and penalizing health care providers have contributed not only to a dearth of abortion services but also to a lack of referral services. Most women agreed that in Palestinian hospitals, particularly governmental ones, abortions were done only when the pregnant woman’s life was in danger or, less commonly, if the fetus had severe anomalies. Even in these circumstances, additional barriers often arose: “Even if one doctor decides that she should abort, she has to consult a committee of doctors and obtain a letter from the religious court.” Furthermore, all interviewed women unanimously confirmed that according to the policies of Palestinian hospitals, they would need their husbands’ permission to abort. As one woman said, “For us here, no wives do things without their husbands’ permission.” As another woman noted, abortion was hard to access not only because of the legal situation in the OPT but also because a woman “can’t go to the doctor other than with her husband’s order.” This legal requirement of physician testimony and subsequent guardian approval introduces a contrived barrier to access, placing women in a position that limits their ability to make decisions about their reproductive health.

Other studies in the OPT have also found similar barriers to abortion access, including the need to obtain the authorization of several doctors, cumbersome requirements for rape and health indications, and the need for spousal consent.[18] One study, based on the results of a 2007–2008 national survey, analyzed the attitudes of Palestinian nursing and midwifery students in the West Bank and Gaza toward abortion and contraception-related policies.[19] Its findings suggested the need to incorporate instruction on laws and policies related to sexual and reproductive health into the curricula of pertinent educational programs. Most recently, the study carried out by AlRifai for the PFPPA used quantitative and qualitative methods to assess safe and unsafe abortions (both spontaneous and induced) among Palestinian women in the Hebron Governorate in the West Bank.[20] The qualitative part of the study involved focus group interviews with health and social work professionals and found that abortion is not an accepted or encouraged practice, even among Palestinian health care providers. Given Palestinian law, hospital requirements, and negative public attitudes toward abortion, Palestinian women’s access to abortion services is severely limited.

Where are Palestinian women obtaining abortions?

Although abortion is illegal, several Palestinian organizations are aiding women in obtaining safer abortions. In 2014, the PFPPA, a Jerusalem-based nonprofit organization, served more than 70,000 women, including more than 10,000 in need of abortion-related services.[21] Because abortion is illegal and highly restricted in the OPT, Palestinian women seeking an abortion are forced to turn to Israeli hospitals, to expensive private Palestinian clinics, or to self-induced termination. One Palestinian hospital staff member who was interviewed as a part of our study said, “We know there are doctors who do it in their private clinics, even if they work [in the hospital]. I work in the hospital so maybe that’s why I know but there are many who don’t know I suspect. The clinics are not publicized for their abortions.” Many women interviewees said that abortion could be obtained in secret through private physicians in Jerusalem and the West Bank, though this would cost a significant amount of money. As one woman explained, “A private place, ****** [a Palestinian hospital in a Jerusalem suburb], can abort for any reason with money compensation, 3,500 shekels. The doctor doesn’t care if the baby is small or big.” A few women made reference to women they knew who had aborted through a private physician. Most often, these physicians willing to perform illegal abortions were discovered through word of mouth.

The clinics that provide abortions seem to all be outpatient clinics, therefore limiting post-abortion care options for women who experience complications or who have self-induced their abortions. One Palestinian patient described the abortion she had through a private doctor:

They told me about a doctor who does it special but he made me pay him a lot. A Palestinian doctor here in Jerusalem, friends told me about him—at first he tells you no, then when he sees you need it, he does it and he had aborted for them so he agrees to abort and told me it’s my responsibility. It was at a private clinic. He told me the shot kills the baby and then he will give me pills for everything to come down. I didn’t go to a hospital after, I stayed at home.

While neither hospital policies nor the law prevent hospitals or physicians from providing post-abortion care, some women may understandably avoid seeking such care out of fear. Some women we interviewed described the situations in which post-abortion care is sought. One woman described the process of a medical termination through a physician prescription: “[The woman] takes Cytotec from the pharmacy and performs the abortion at home and she comes to the hospital bleeding. So to save her life they do an E&C [evacuation and curettage]. It requires a prescription and they get a prescription with money from the doctor.”

Other women told stories of themselves or friends trying to induce their own abortions at home, with some believing that they had successfully caused their own abortion. One woman said, “I know some who aborted at home: jumped, carried heavy things, or let her kids jump on her. And then she aborted and went to the hospital for cleaning.” One woman described her own attempt:

Every day for 4 months of my pregnancy I would jump for about half an hour. It would hurt. On the stairs, off my bed to the floor back to the bed. I wasn’t merciful to myself at all. It would hurt. I lost hope that it would abort, but then at 4 months it aborted at home. I got blood coming down. And at that point, I was sad. As if I hadn’t tried for this. So then I came here to the hospital so they put a pill for pain and they did a cleaning.

Restricted access to abortion can thus lead both to poor post-abortion care and to increased morbidity and mortality among women who take abortion into their own hands. A 2014 documentary, Unsafe Abortions in Palestine, paints a grim narrative of the medical and social factors limiting access to safe abortion services in much of the region, which results in Palestinian women pursuing unsafe abortion methods.[22] This film received support and publicity from local and international organizations such as the International Planned Parenthood Federation, Juzoor (a Palestinian NGO), and the PFPPA. As one woman we interviewed said, “She might die if abortion is not done in a legal way.” Another woman explained, “Abortion can be dangerous to the mom’s health. If she has an abortion in a place that’s not reliable or safe, she could have negative effects later, she could even die after abortion.”

These women’s voices reinforce the well-established evidence that shows an association between unsafe abortion and restrictive abortion laws.[23] The median rate of unsafe abortions is 23 per 1,000 abortions in the 82 countries with the most restrictive laws, compared with 2 per 1,000 in countries that allow abortions.[24] Abortion-related deaths are more frequent in countries with more restrictive abortion laws (34 deaths per 100,000 childbirths) than in countries with less restrictive laws (1 or fewer per 100,000 childbirths).[25] Worldwide, approximately 42 million women with unintended pregnancies choose abortion yearly, and nearly half of these procedures are unsafe.[26] Five million of these women will suffer long-term health complications, and about 68,000 die of unsafe abortion annually, making it one of the leading causes of maternal mortality.[27] Nonetheless, less restrictive abortion laws do not guarantee safe abortions for those in need, as access to health care is also required. Both liberalizing abortion law and improving abortion access face social, religious, and political obstacles.[28]

The effect of the Israeli occupation on abortion access

The obstacles to safe abortion provision and care are compounded by the realities of living under occupation. Due to the Israeli military occupation that began in 1967, Palestinians have been divided into different territories, namely East Jerusalem, the West Bank, and Gaza. The West Bank and Gaza are under distinct Palestinian rule but largely remain under Israeli military and civil control. East Jerusalem is a highly contested territory, and Palestinians living there have a “permanent residency” status, which confers fewer rights than citizenship.[29] Palestinians in the OPT can carry one of three types of IDs, each of which defines where they are allowed to freely travel within the region. The Jerusalem ID allows holders to reside in Jerusalem and enter the West Bank; the West Bank ID prevents those living in the West Bank from entering Jerusalem without applying for special permission; and the Gaza ID prevents residents from leaving Gaza. Beyond ID status, movement is largely restricted within and from the West Bank by a complex series of bureaucratic and physical obstacles, including the need for special permits to enter Jerusalem, military checkpoints, roads forbidden to Palestinians, and an eight-meter-high, 700-kilometer-long concrete separation wall that separates the West Bank from Jerusalem and Israel.[30]

Given the geographically and politically fragmented nature of the OPT imposed by the occupation, abortion laws and access differ depending on whether a Palestinian woman lives in East Jerusalem, the West Bank, or Gaza. When we asked Palestinian women living in Jerusalem about the accessibility of abortion services, one woman responded, “Access is easier here in Jerusalem and the laws in Jerusalem are light because anyone has the right no matter what. Even without a religious indication.” Another woman responded, “It’s easy if she has an Israeli ID because she can just go to an Israeli hospital. I don’t know what they do in the West Bank.”

While residents of Jerusalem have access to Israeli hospitals and residents of Jerusalem and the West Bank have access to private clinics if they can find and afford them, women interviewees felt that there is virtually no access to abortion services in Gaza. As one woman from Gaza said, “No, it is not allowed in any case in Gaza. For any reason. The doctors don’t allow it in any case. [Interviewer: Even for medical reasons or fetal anomalies?] Yes, even so.” Another woman explained, “It is pretty much impossible in Gaza. … In Gaza, there are no private clinics and they can’t leave.” When asked why there were no private clinics in Gaza, another woman responded, “Doctors in Gaza refuse to completely, based on what I know and my relation with the community, it’s a small area and everyone knows everyone.”

Women in Jerusalem seem to have the most access to abortion due to the availability of both Israeli hospitals and private clinics, while women in Gaza seem to have the least due to the absence of private clinics and the general restrictions on leaving Gaza. The majority of Palestinian women do not have access to Israeli hospitals due to checkpoints, the separation wall, and the need for special permits to enter Jerusalem. One of the only alternatives is therefore to pay a private physician to perform an illegal abortion at a private clinic for a significant fee, making this option less accessible to women of lower socioeconomic status. This is consistent with literature on clandestine abortions in the Middle East and North Africa, which notes that such abortions are provided largely by gynecologists and other physicians, with the quality of service depending on the patient’s ability to pay, access to pain relief, and the use of modern or traditional abortion methods.[31] Unlike other studies in Palestine and the Arab world, the women we interviewed did not frequently mention the option of a midwife or nurse performing an abortion.[32] The few women interviewees from Gaza had special travel permits that are extremely difficult to obtain.[33] These women indicated that there were really no options for safe abortion in Gaza because hospital policies are particularly restrictive and there are no known private physicians willing to perform abortions. The permits that allowed these women to leave Gaza for medical treatment would not be sought by Gazan hospitals on behalf of women seeking abortion, making it virtually impossible to obtain a safe abortion as a Gazan woman.

Abortion through Israel: A unique quandary

Although abortion is illegal under Palestinian law unless there is a risk to the mother’s life, Palestinian women are in a unique situation compared to other women in the MENA region in that they live only a few miles from a country where abortion is legal, easily accessible, and even government funded for its own citizens.[34] Israel, despite its religious, right-wing government, is among the world’s most liberal countries when it comes to abortion. In 2014, the Israeli Cabinet updated a 1977 law to allow abortion if approved by a termination committee.[35] It is reported that these committees, composed of two doctors and a social worker, approve 98% of abortion requests, making abortion widely available to people living in Israel.[36] East Jerusalem, where our study was conducted, provides a unique legal and medical setting in which to evaluate abortion access for Palestinian women due to the presence of Israeli law and Palestinian principles. Interestingly, Palestinian hospitals in East Jerusalem operate in a dual fashion, generally applying Palestinian principles and policies but conforming to Israeli medical law for legal and malpractice purposes. The result of this is a complex system in which law and practice diverge. For example, physicians in Palestinian hospitals in Jerusalem are legally bound to recommend abortion during options counseling for patients diagnosed with fetal anomalies, even though the hospital itself will not provide terminations for these cases.[37]

When asked how a Palestinian woman might access an abortion if refused at a Palestinian hospital, many women answered that they could obtain one at an Israeli hospital, to which only Palestinian women living in Jerusalem or who have permits to enter Jerusalem from the West Bank have access. As one woman said:

In Jerusalem, people have access to Israeli hospitals, even for an undesired pregnancy. … They don’t have limits to 120 days like we do. Anytime she wants a termination, inshallah [God willing] even the day before she’s due, they’ll do it for her. ****** [An Israeli hospital] and other hospitals are private anyway and they have a committee but it’s easy for a lot of things: unwanted pregnancies, illegal pregnancies, rape. They’ll do it for anyone. So anyone who intends to get an abortion and can’t get one here [at Al-Makassed] can go to them.

One woman said, “My sister’s sister-in-law was pregnant with a baby with Down syndrome and she came here [to Al-Makassed Hospital] and they wouldn’t abort so she went to ****** [an Israeli hospital] and got an abortion.” As permanent residents, Palestinian women who live in East Jerusalem but are not citizens of Israel are still part of the Israeli health care and insurance system, and thus theoretically have access to abortion.[38] Palestinian women who do not live in East Jerusalem but have access to Jerusalem through special permits can also potentially access abortion, although they would have to pay a significant amount of money out of pocket given that they are not part of the Israeli health care system. As one woman explained, “It’s expensive for her to come to do it [an abortion] at an Israeli hospital. But they won’t do it for her at a Palestinian hospital in Jerusalem. For Israelis, they’ll do it for them for free because they have insurance. But Palestinian women often don’t.”

While Israeli clinics and hospitals provide a unique option for a limited group of Palestinian women to obtain abortion services, the barriers to accessing abortions through the Israeli system are not only geographic and financial but psychological and political. One interviewee living in Jerusalem expressed her strong feelings about abortion access at the intersection of multiple legal systems:

We consider ourselves an occupied country. Israeli law is stronger than Palestinian law in Jerusalem. The West Bank has different laws. Israel is of course concerned with women’s rights more. They don’t have a religious view on it anyway. If anything, they let her abort more. So in the environment that I live in, I don’t let Israeli law decide my rights or that I have to abort. This is my decision and my husband and my home and family’s. I run by Palestinian laws. Israeli law definitely allows abortion more. But Palestinian law does not and that is what I follow.

In this way, Palestinian women might feel loyalty to their own laws and customs when it comes to reproductive health rights, even if they are more restrictive, in sociopolitical solidarity and moral resistance against the occupier. The women we interviewed made direct reference to this sense of loyalty many times, indicating that procreating directly defied the occupying force.[39] As one woman explained, “To have a baby here is a form of resistance and annoyance to our occupier. … I don’t support a woman who jumps and jumps to abort the baby. Why should the Palestinian woman not have children? She should have! In order to challenge the occupier.” This glorification of motherhood and procreation has a well-established history in the OPT, developing in response to Zionist political agendas since 1948 to ensure that the Israeli population in Israel far outnumbers the Arab one.[40] One of the main characteristics of the occupation has been the containment of the Palestinian population within restricted areas and the systematic movement of Israeli settlers onto Palestinian land in East Jerusalem and the West Bank.[41] As a result, population growth and control have become crucial instruments for both Israelis and Palestinians, each attempting to outnumber the other to gain control over land.[42] The Palestinian Liberation Organization and the Palestinian Authority supported this pro-natalist policy among Palestinians as a form of resistance to occupation.[43] In this way, motherhood acquires a political status among Palestinians that may be empowering but not necessarily challenging to traditional gender roles or to the standing social order.[44]

As Rhoda Kanaaneh points out in her book Birthing the Nation: Strategies of Palestinian Women in Israel, one of the effects of occupation has been the politicization of reproduction, procreation, fertility, and most of all, the source of these, the Palestinian woman.[45] Women have come to be considered the markers of national boundaries, with the duty to produce the babies that the nation requires.[46] This, in turn, informs the ways in which Palestinian women make and judge reproductive decisions, evident in the way some of the Palestinian women we interviewed resisted abortion on these nationalistic grounds.[47] This politicization of reproduction is not unique to Israel and Palestine, as the idea of “power in numbers” has been influential in many postcolonial nations and for dispossessed minorities striving to assert their legitimacy.[48]

Given the distrust of the Israeli occupation, many interviewees expressed doubt about the intentions of the Israeli physicians who performed abortions for Palestinian women.[49] As Kanaaneh points out, one of the major effects of both Israelis and Palestinians politicizing reproduction has been the development of distrust, especially on the part of Palestinians, of family planning initiatives and medical care.[50] Kanaaneh reports in her research that Israeli motives for encouraging contraception and abortion among Palestinians are considered suspect enough that many Palestinian women lie to the doctors and nurses from whom they seek care.[51] There has been significant literature about Zionist political movements and initiatives that view Palestinian fertility as a threat, which some argue has influenced how contraception and abortion services are provided to Palestinians in particular. This has led to distrust even of Palestinian family planning initiatives, such as those of the United Nations Relief and Works Agency, the PFPPA, and the Palestinian Authority.[52]

This distrust and doubt was reflected in our interviews with Palestinian women. As one woman pondered, “Maybe Israeli hospitals will do it [abortion] to stop Palestinian women from procreating.” Another woman said, “I don’t believe in Israeli medicine, they’ll just tell Palestinians that they have fetal anomalies so that they abort.” One woman related such an incident: “I knew someone, whom they told at the Israeli hospital to abort for Down’s syndrome. She didn’t allow it and the baby was born normal. Maybe this is racism, they want to get rid of us.” Although this sentiment was relatively common, a few women disagreed. One said:

The goal of medicine in Israel, yes, they are enemies, but in a medical sense, they’re like Arabs exactly. I’ve never seen harm on the part of Israeli medicine. I think it’s excellent. Arab medicine is also good. I don’t think Israelis harm us medically, or people say they tell a Palestinian woman to abort in order to take advantage. This has not happened. I haven’t heard it. I’ve seen a lot in this life and this community, I’ve never heard an Israeli doctor tell a Palestinian woman to abort in order to get revenge, I’ve never heard, this has not happened at all. Quite the opposite, if you ask an Arab woman here with a Jerusalem ID, they prefer Israeli hospitals like ******, because insurance covers us in Israeli hospitals. … From what I’ve seen the Israeli hospitals are very good.

Whether or not women agreed with the practice of seeking care at Israeli hospitals, they recognized that Israel presents an option for legal abortion for some Palestinian women, a unique situation in the OPT specifically and the MENA region in general.

Conclusion and future directions

Palestinian women face multiple barriers to accessing safe abortion in the OPT, many of which are unique to living under occupation and at the interface of multiple legal systems. The worsening political situation and humanitarian crisis has had a negative impact on Palestinian women’s health by lowering the priority and funding of many sexual and reproductive health policies and programs.[53] Limitations to abortion access by Palestinian women include legal restrictions, hospital policy restrictions, prohibitive prices at private clinics, fear of stigma induced by the occupation, and travel restrictions related to place of residence. Because abortion is illegal under Palestinian law and highly restricted in the OPT, Palestinian women are forced to turn to Israeli hospitals, to expensive private Palestinian clinics, or to self-induced termination when seeking an abortion. While Israeli clinics and hospitals provide a unique option for a limited group of Palestinian women, this reality is fraught with ethical and political implications that are keenly felt by Palestinians and complicate the abortion landscape. Thus, the barriers to accessing abortion under occupation are not only geographic and financial but also psychological and political. A deep understanding of the interplay between the political and historical context of occupation and its effects on reproductive rights and choice is crucial in the war-torn context of Palestine for those working to provide better support and access for Palestinian women navigating the intimately challenging circumstances of abortion.

Sarrah Shahawy, MD, is an obstetrics and gynecology resident physician at Northwestern University McGaw Medical Center, Chicago, USA.

Please address correspondence to the author. Email: sarrah.shahawy@northwestern.edu.

Competing interests: None declared.

Copyright © 2019 Shahawy. This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non- commercial use, distribution, and reproduction in any medium, provided the original author and source are credited.

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[2]. R. Horton, “The occupied Palestinian territory: Peace, justice, and health,” Lancet 373 (2009), pp. 784–788; A. Becker, K. Al Ju’beh, and G. Watt, “Keys to health: Justice, sovereignty, and self-determination,” Lancet 373 (2009), pp. 985–987.

[3]. Horton (see note 2); R. Giacaman, R. Khatib, L. Shabaneh, et al., “Health status and health services in the occupied Palestinian territory,” Lancet 373 (2009), pp. 837–849.

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[11]. Convention on the Elimination of All Forms of Discrimination against Women, G.A. Res. 34/180 (1979).

[12]. Jordanian Penal Code No. 16 of 1960. Available at https://jordan-lawyer.com/2017/04/05/jordan-criminal-law.

[13]. Ibid.

[14]. Public Health Law. No. 20 (2005). Available at http://www.hdip.org/public%20health%20law%20English.pdf.

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[16]. S. Shahawy and M. B. Diamond, “Perspectives on induced abortion among Palestinian women: Religion, culture and access in the occupied Palestinian territories,” Culture Health and Sexuality 20/3 (2017), pp. 289–305.

[17]. Ibid.

[18]. Hessini (see note 15).

[19]. St-Jean (see note 6).

[20]. AlRifai (see note 7).

[21]. Y. Schwartz, “Palestine’s abortion problem,” Foreign Policy (December 4, 2015). Available at https://foreignpolicy.com/2015/12/04/palestines-abortion-problem.

[22]. International Planned Parenthood Federation, Unsafe abortion in Palestine. Available at http://www.ippf.org/resource/Unsafe-abortion-Palestine.

[23]. L. B. Haddad and N. M. Nour, “Unsafe abortion: Unnecessary maternal mortality,” Reviews in Obstetrics and Gynecology 2/2 (2009), pp. 122–126.

[24]. D. A. Grimes, J. Benson, S. Singh, et al., “Unsafe abortion: The preventable pandemic,” Lancet 368 (2006), pp. 1908–1919.

[25]. World Health Organization, Unsafe abortion: Global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008, 6th ed. (Geneva: World Health Organization, 2011).

[26]. Haddad and Nour (see note 23).

[27]. Grimes et al. (see note 24).

[28]. Haddad and Nour (see note 23).

[29]. B’Tselem, East Jerusalem. Available at https://www.btselem.org/jerusalem.

[30]. Winter et al. (see note 4).

[31]. Hessini (see note 15); S. D. Lane, J. M. Jok, and M. T. El-Mouelhy, “Buying safety: The economics of reproductive risk and abortion in Egypt,” Social Science and Medicine 47/8 (1998), pp. 1089–1099.

[32]. AlRifai (see note 7); Shahawy and Diamond (see note 16).

[33]. Shahawy and Diamond (see note 16).

[34]. Schwartz (see note 21).

[35]. Penal Law, 5737-1977, ch. 10, art. 2; International Covenant on Economic, Social and Cultural Rights, G.A. Res. 2200A (XXI) (1966), art. 12; D. Kamin, “Israel’s abortion law now among world’s most liberal,” Times of Israel (January 6, 2014).

[36]. Kamin (see note 35).

[37]. Shahawy and Diamond (see note 16).

[38]. Schwartz (see note 21).

[39]. Shahawy and Diamond (see note 16).

[40]. R. A. Kanaaneh, Birthing the nation: Strategies of Palestinian women in Israel (Berkeley: University of California Press, 2002).

[41]. Bosmans et al. (see note 8).

[42]. J. Abu-Lughod, “The demographic war for Palestine,” Link 19 (1986).

[43]. Kanaaneh (see note 40).

[44]. J. Peteet, “Icons and militants: Mothering in the danger zone,” Signs 23/1 (1997), pp. 103–129.

[45]. Kanaaneh (see note 40).

[46]. Haddad and Nour (see note 23); Hessini (see note 15).

[47]. Kanaaneh (see note 40); Shahawy and Diamond (see note 16).

[48]. Kanaaneh (see note 40); E. T. Zureik, “Constructing Palestine through surveillance practices,” British Journal of Middle Eastern Studies 28/2 (1999), pp. 205–227.

[49]. Shahawy and Diamond (see note 16).

[50]. Kanaaneh (see note 40).

[51]. Ibid.

[52]. Ibid.

[53]. Bosmans et al. (see note 8).