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Causes and consequences of unintended pregnancies in the Gaza Strip: a qualitative study
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  1. Bettina Böttcher1,
  2. Mysoon Abdelaziz Abu-El-Noor2,
  3. Nasser Ibrahim Abu-El-Noor2
  1. 1 Faculty of Medicine, Islamic University of Gaza Faculty of Medicine, Gaza, Palestine
  2. 2 Faculty of Nursing, Islamic University of Gaza Faculty of Nursing, Gaza, Palestine
  1. Correspondence to Dr Bettina Böttcher, Faculty of Medicine, Islamic University of Gaza Faculty of Medicine, Gaza, Palestine; bettina.bottcher{at}yahoo.co.uk

Abstract

Background Little is known about unintended pregnancies in the Gaza Strip. This study explored causes and consequences of unintended pregnancies among women in the Gaza Strip.

Methods This was a qualitative study, and included 21 women who had experienced unintended pregnancies previously. Data collection took place in three focus groups of 5–12 participants, which were facilitated by one female researcher. Structured questions on reasons for, causes and impact of unintended pregnancies were answered by all participants. Sessions were audiotaped and responses were transcribed and read by all the researchers to extract themes.

Results The mean age of participants was 34.2±6.0 years, parity was 2.7±0.6 and 16 participants (76.2%) had benefitted from secondary level education or above.

Five main themes were identified: (1) economic hardship was the main reason for pregnancies to be unwanted; (2) high pressure was exerted on women for male babies, exposing women to gender-based violence; (3) advanced maternal age was perceived as a social stigma; (4) complete lack of support for women facing unintended pregnancy led to self-management of terminations including attempts of unsafe methods; and (5) changes of methods and incorrect use leading to contraceptive failure was the most frequent cause.

Conclusions Unintended pregnancies in the Gaza Strip are a common cause of distress for women. The most effective way of preventing unintended pregnancies remains access to reliable contraception. However, a service designated to support women facing unintended pregnancies is needed in the Gaza Strip. Local policymakers have to address this when planning healthcare services.

  • unintended pregnancy
  • contraceptive failure
  • gender based violence
  • long acting reversible contraception
  • Gaza Strip
  • Palestine

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Key messages

  • Although largely ignored, unintended pregnancies are common in the Gaza Strip.

  • Pressure on women to have male offspring was often combined with verbal or physical violence, leading to high degrees of distress among women.

  • Two-thirds of participants attempted to self-manage termination of their pregnancies, demonstrating the need to provide services for women experiencing unintended pregnancies.

Introduction

Unintended pregnancies include unwanted and mistimed pregnancies and comprise 40% of pregnancies worldwide.1 They contribute to maternal mortality and morbidity and can negatively affect children’s health.2 3 Negative impact of unintended pregnancies has been shown in psychosocial, health and economic terms.1 2 Furthermore, spacing of pregnancies has a positive impact on maternal and children’s health.2 Therefore, reliable contraception has been cited as a major factor in the achievement of the United Nations Sustainable Development Goals No 3 (Good Health and Wellbeing) and No 5 (Gender Equality). Universal access to good-quality sexual and reproductive health (SRH) services is one key strategy to improve the well-being of women and children.4

Various estimates have been given for the prevalence of unintended pregnancies ranging from 13% to 82% of pregnancies worldwide.5–9 However, only a few studies are available from the Middle East and North Africa, giving a prevalence of 40% in Iran and 24% in Egypt.5 10–12 This paucity of data might be due to more pressing health priorities in areas of conflict and economic hardship, but social determinants might also play a role, valuing large families and negating the occurrence of unintended pregnancies. Very little is known about unintended pregnancies in the Gaza Strip. Termination of pregnancy is illegal in Palestine and contradicts prevalent religious values, except if the mother’s life is at risk.13 No governmental services are provided for women facing unintended pregnancies, posing further difficulties for women. However, SRH services are widely provided free of charge to women in the Gaza Strip in clinics run by the government or the United Nations Relief and Works Program (UNRWA).14 15 These are easily accessible to most women and provide basic contraceptives, although not all methods are available and frequent shortages restrict women’s choices.16 Women attending SRH services regularly report unintended pregnancies to their healthcare providers. The paucity of local data in this field makes more research necessary. Consequently, this study aimed to explore the causes and consequences of unintended pregnancies in the Gaza Strip.

Methods

Design, setting and sampling

Data for this qualitative study were collected in a healthcare centre providing SRH services to women. In total, 21 women were recruited into three focus groups by purposeful sampling targeting women aged 18 years or older who had experienced unintended pregnancies at any time in the past. A total of 94 women had been documented by this centre to have experienced an unintended pregnancy. From these, 55 women were able to be contacted and invited to attend the focus group discussions, of which 21 (38.2%) attended.

Focus groups were facilitated by one female researcher, who was not a healthcare provider in this facility. Each focus group consisted of 5–12 participants. After explanation of the purpose of the study and obtaining a written consent from each participant, structured questions were asked, the same in every focus group, and answers invited (see online supplementary data file S1). The sessions were audio-recorded and then transcribed, including every question and all answers. An agreement of complete confidentiality was made prior to the start of the session and participants’ contributions were kept anonymous.

Supplemental material

Ethical considerations

Ethical approval for this study was obtained from the Human Resources Department of the Palestinian Ministry of Health (MoH), which is the body in Gaza which issues ethical and administrative approvals for studies involving humans. Further approval to conduct the study was obtained from the administrative body of the healthcare centre, where data collection was conducted.

Data analysis

Data were analysed through careful reading of the responses by each researcher followed by identifying, coding and categorising the data and using thematic analysis to process the qualitative information.17 Throughout data coding the research team extracted themes and gave an appropriate label for each. Some quotes from the participants are presented to provide a comprehensive illustration of these themes.

Patient and public involvement

No patient or public involvement was sought when designing this study.

Results

Participant characteristics

The mean age of participants was 34.2±6.0 years and their parity was 2.7±0.6 with 28.6% (n=6) having completed university and 47.6% (n=10) secondary school. Average household income was poor but the range was wide (table 1). The pregnancy outcomes were variable, including births, miscarriages and self-induced terminations, but this was not quantified. Five main themes were identified.

Table 1

Sociodemographic characteristics of participants

Factors in unwanted pregnancies

Economic hardship

All participants reported financial difficulties with unemployment and lack of opportunities. This ranged from no regular family income and dependence on food handouts to small incomes that barely covered a family’s needs and was the most common reason for pregnancies to be unwanted; the only reason for some, as one woman reported: "I have two boys and four girls. This is enough for us as we live in a small house for rent". For many, it was difficult to cope with increasing numbers of children. With husbands being unemployed, many participants felt that care for the family fell to them entirely, which was expressed by one woman: "He leaves the house and the children are left with me".

Demand for male offspring

Eight (38.1%) women mentioned that they did not want to have further pregnancies, but their husbands wanted more boys. This led to distress, described by one as follows: "I had a Caesarean section and did not want to get pregnant quickly again. I was afraid and wanted to terminate the pregnancy". The wish for more boys by husbands and their families also resulted in fears among participants of having female babies. Threats or even violence towards them or towards their children was reported by six (28.6%) participants. Common perpetrators were the husbands, but two also described involvement of mothers-in-law. One woman narrated her experience as follows: "I have a boy and two daughters. My mother-in-law told me that if I bring another girl, they will throw her down the stairs". Another one said: "Thanks to God, I had twin boys. I wanted to get rid of them. I threw myself down [to induce abortion]. I was scared they would be girls. My husband and his mother hit me and threatened me if they were girls."

Advanced maternal age

Women who were over 40 years old felt they were too old for another pregnancy. They feared social stigma associated with pregnancies at this age. One said: "I was 45 years old [when I got pregnant] and already have five children. I saw the doctor, but he did not give me the tablet to help me miscarry. I took the vaginal tablet at home myself and miscarried.’’ Another one explained: "I was 40 years old. I miscarried. I was pregnant, but did not want to be. I was scared people would blame me". In general, participants agreed that pregnancies in older women would lead to children with health problems and were not desired. Interestingly, their attitudes not only illustrated, but also supported, the social stigma attached to pregnancies in older women.

Barriers to effective contraceptive use

Incorrect use was the most common reason for contraceptive failure, reported by 14 (66.7%) women, often associated with a change of contraceptive method. One woman said:"The physician changed the pills to a different type. After I got pregnant he told me that I made a mistake and started with the wrong pill".

Serious health conditions or side effects were common reasons for the change, while three women reported unavailability of their usual contraceptive in Gaza. A typical comment was: "My health condition does not allow me to use most of the contraceptive methods. We used condoms, but I got pregnant".

Lack of support

A shared experience by all participants was lack of family, social and professional support and not knowing where to go when experiencing an unintended pregnancy. Healthcare professionals in antenatal clinics were described as unsympathetic: "When I went to the antenatal clinic, the nurse told me that I should not have got pregnant and she blamed me for being pregnant". A significant number of women (71.4%; n=15) reported trying to terminate their pregnancies by using oral and even vaginal prostaglandins without medical supervision. Two women resorted to unsafe methods such as jumping from heights or herbal mixtures. Termination of pregnancy is highly restricted in the Gaza Strip,13 increasing the feeling of isolation among women.

Discussion

This study demonstrates the need for innovating a designated service for women facing unintended pregnancies. Such a service is only available at one healthcare centre in the Gaza Strip. A wide variety of reasons for the pregnancies being unwanted was given from financial and social difficulties to advanced maternal age. The factors that caused the unintended pregnancies were more uniform and included incorrect use or change of contraceptive methods. A surprisingly large number of women sought and attempted to terminate their pregnancy without medical supervision.

Determining prevalence of unintended pregnancy can be difficult, as not all women will report a pregnancy being unintended and pregnancy intention changes over time. Many studies were conducted using retrospective data collection once the pregnancy had occurred, when women might be hesitant to label their pregnancy as ‘unintended’ or ‘unwanted’.18 So far, no reliable data are available about prevalence in the Gaza Strip. Despite the obvious neglect of this topic, the current study confirmed that a significant number of unintended pregnancies occur. However, sociodemographic determinants of unintended pregnancies were not the same as in other studies, where poor educational achievements were a commonly reported determinant.5 6 18–20 In contrast, 76.2% of women had benefitted from secondary level education in this study. One reason for this could be the generally high level of education of girls in the Gaza Strip. Another, more significant, reason might be that this study only included women who sought SRH advice, and more women with poorer educational achievements would not seek such advice and might have higher numbers of unintended pregnancies. Further discrepancies were those of parity and age. Whereas other studies reported higher parity and higher age to be determinants for unintended pregnancies, mean parity and age were not extraordinarily high in this study.6 19 20

This study identified a variety of reasons for pregnancies to be unwanted with the most common reason being financial difficulties. This is in concordance with other studies that found a significantly higher prevalence of unintended pregnancies in low-income countries when compared with high-income countries.6 19 21 22 In addition to this, the Gaza Strip, being an area of conflict and insecurity with poor economic prospects and high unemployment, might influence this decision among women, and indeed fertility rates are constantly decreasing.14

One notable aspect was the pressure that women felt to produce male offspring, some suffering verbal or even physical violence.5 23Gender-based violence (GBV) has been poorly addressed in the Gaza Strip and a report by the United Nations Population Fund (UNFPA) from 2016 showed that reporting of GBV was only estimated at 54% and largely supported by non-governmental organisations.23 However, the same report also pointed at increasing efforts to address GBV on different levels including policymaking and capacity building. The current study confirms this to be an urgent need for women in the Gaza Strip. Public life and many institutions remain dominated by men and frequently do not reflect women’s concerns and challenges adequately, as shown by the results of this study, where experiences of women facing unintended pregnancies were not reflected in current provision of SRH services.

Surprisingly, a large number of participants admitted to trying to terminate their pregnancy without medical supervision. Termination of pregnancy is illegal and contradicts with religious values prevailing in the Gaza Strip, unless the mother’s health is at risk. The WHO categorisation of termination of pregnancy includes ‘safe abortions’, which are safe methods performed by trained practitioners; ‘less safe’, which include safe methods performed by untrained practitioners; and ‘unsafe’, which are dangerous procedures.24 In this study, 28.6% of participants reported having attempted termination of their pregnancies, which is not an accurate number, as disclosure by participants was not prompted. Most attempts at termination of pregnancy fell into the ‘less safe’ category and only two in the ‘unsafe’ category. A study conducted among Irish women, accessing termination of pregnancy abroad, also found that unsafe methods had been considered, although not attempted.25 Nevertheless, ‘less safe’ termination can also lead to serious complications,3 24 26 posing a threat to women’s lives, especially as exact gestational age is often not established.

The most effective way to reduce the incidence of ‘less safe’ and ‘unsafe abortions’ is to reduce the incidence of unintended pregnancies.5 26 27 On one hand, this includes the provision of easy access and free contraceptive services to all women, which is possible in the Gaza Strip at government or UNRWA healthcare centres.4 However, not all contraceptive methods are available at all times.28 29 Sudden unavailability of a used method can make it necessary for women to swap to a different method, which has been one of the main factors identified in this study to lead to unintended pregnancies. Recurring shortages of supply in contraception to the Gaza Strip highlight the need for greater choice of long-acting reversible contraception (LARC). However, the UNFPA, the sole provider of contraception to Palestine, has made budget cuts in June 2017, reducing these supplies, and potentially causing more shortages.16 The impact of this on prevalence of unintended pregnancy has yet to be observed.

In Gaza, the most common contraceptive choices among women are combined oral contraceptive pills followed by condoms and only thereafter by the intrauterine contraceptive device or medroxyprogesterone injection, which are the only LARC methods freely available in Gaza.20 25 The hormonal implant is only available at a few centres for a price, which often precludes its use for women. This shows that although the use of modern contraceptives has been reported to have increased in Gaza, there is still need for improvement, especially in making a choice of LARC widely available.30 Furthermore, such efforts need to be complemented by services that address unintended pregnancies openly and provide support for women facing them.25 This study demonstrates the potential of such interventions to reduce negative health impacts on women as a result of unintended pregnancies.

The strengths of this study include the setting, which allowed women to speak freely and disclose issues, that might have not come to light in a questionnaire survey or different setting.

Limitations are the small sample size and the fact that only women already accessing SRH services could be reached by this study. Furthermore, in order to keep the discussion in the focus groups open, no systematic information was collected on pregnancy outcomes or self-induced abortion.

Conclusions

Although the exact prevalence of unintended pregnancies in the Gaza Strip is not known, they are common and cause anxiety and distress to women, leading some women to attempt ‘less safe’ and even ‘unsafe’ methods to terminate their pregnancies. The most effective way of preventing unintended pregnancies remains access to reliable contraception. However, a service designated to support women facing unintended pregnancies is needed in the Gaza Strip. Local policymakers have to address this issue openly when planning healthcare services.

References

Footnotes

  • Contributors BB contributed to design and planning of the study, as well as to data collection, and she drafted and approved the manuscript. MAEN contributed to design and planning of the study, as well as to data collection, and she revised and approved the manuscript. NAEN contributed to design and planning of the study, and he revised and approved the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Ethics approval No Institutional Review Boards (IRBs) exist in the Gaza Strip. Ethical approval for this study was obtained from the Human Resources Department of the Palestinian Ministry of Health (MoH), which is the body in Gaza that issues ethical and administrative approvals for studies involving humans. Further approval to conduct the study was obtained from the administrative body of the Women’s Centre where data collection was conducted. Formal written consent was obtained from all potential participants prior to taking part in this study. The purpose of the study was explained to all participants as well as the fact that taking part in this study was completely voluntary and had no effect on the medical care they received. Complete confidentiality was agreed and kept, and anonymity was secured for data transcription.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Obtained.