Intensity of conflict and fertility in the occupied Palestinian territory: a longitudinal study

Background The occupied Palestinian territory has one of the highest fertility rates in the world. We examined the association between the intensity of conflict in the region and the fertility behaviour of Palestinian women. Methods Intensity of conflict was measured using information from the human rights organisation B’Tselem on the yearly number of Palestinians killed for the period 1993–2009. The outcome variable, fertility, was investigated using birth history data from the 2010 Palestinian Family Health Survey. Cox regression models were used to assess the association between number of fatalities and women's likelihood of starting childbearing, adjusting for secular trend and relevant covariates. Findings According to B’Tselem data, 5268 Palestinians were killed between 1993 and 2009. Birth history data from the 2010 Palestinian Family Health Survey included a total of 6292 first conceptions during the study period. We found a significant positive association between intensity of conflict and fertility after adjustment for time trend (1990s, 2000s), governorate (North Gaza, Gaza, Dier El-Balah, Khan Yunis, Rafah, Jenin, Tubas, Tulkarm, Nablus, Qalqiliya, Salfit, Ramallah and Al-Bireh, Jericho, East Jerusalem, Bethlehem, Hebron), locality type (urban, rural, and refugee camp), household wealth (poorest, poor, middle, rich, richest) and woman's education (less than secondary, secondary or higher). A 1% increase in the yearly number of fatalities was associated with a 12% increase in the likelihood of starting childbearing for women in the Gaza Strip (hazard ratio 1·12; 95% CI 1·07–1·16) and a 9% increase for women in the West Bank (1·09; 1·06–1·13). Interpretation The results are relevant to the design of reproductive health interventions in emergency situations. Although the precise mechanisms of association between conflict and conception are not addressed here, efforts to maintain and strengthen family planning programmes during times of more intense conflict might be considered