Reproductive health and rights in East Jerusalem: the effects of militarisation and biopolitics on the experiences of pregnancy and birth of Palestinians living in the Kufr ‘Aqab neighbourhood

Abstract Research with marginalised communities points to the need to understand political determinants of reproductive health. For residents of Kufr ‘Aqab neighbourhood, Israeli biopolitics in East Jerusalem can be barriers to access to maternal health. This is manifested in women having to cross military checkpoints to give birth in hospitals located in Jerusalem to make their children eligible for “permanent residency”, a document required for Palestinians to live in Jerusalem. A basic qualitative design is utilised, and semi-structured in-depth interviews with 27 women and 20 men were conducted and thematic analysis was used to extract themes and subthemes. Women reported exposure to risky conditions during pregnancy and worries of giving birth at checkpoints. Social support was restricted for some women due to inability of the husband/family to reach the hospital at the time of birth. Men reported distress related to inability to attend birth. Giving birth in a Jerusalem hospital, as part of passing residency to children, was perceived as reaffirming Palestinian presence in the City and transforming sites of suffering to sites of resistance. Israeli residency policies and segregation of Jerusalem affect Kufr ‘Aqab residents’ pregnancy and birth on physical, social and psychological levels. Results indicate the importance of incorporating political determinants of access to maternal care and safe pregnancy in the conceptualisation of reproductive rights.


Introduction
Conceptualisation of reproductive rights centres around individual freedom of choice with regards to number, spacing and timing of children. 1 Research in contexts of structural injustice, colonialism and conflict indicates the failure of this approach to account for political determinants of reproductive health (RH). [2][3][4][5][6] Studies from East Jerusalem show that pregnancy and birth are interwoven with Israeli discriminative biopolitical practices towards Palestinian residents of the city. 2 Israeli biopolitics, "the production, maintenance and control of 'undesirable' populations", [2, p. 1201] are practiced through segregation of the city from the rest of the occupied Palestinian territories (West Bank and Gaza Strip) and by restricting where East Jerusalem Palestinians can live and give birth. 7,8 Only Palestinians with "permanent residency" can live and work in East Jerusalem. They must continuously prove that they are residing within the boundaries dictated by Jerusalem's municipal authorities or lose their residency. Moreover, passing residency to newborns requires that the mother delivers in a Jerusalem hospital. These requirements do not apply to Jewish residents who can be born and live outside Jerusalem boundaries without losing the right to reside in the city. Our study focuses on Kufr 'Aqab neighbourhood that was excluded from East Jerusalem after the construction of the separation wall starting in 2002. 9,10 Since many of the people living there are Jerusalem residents and because the neighbourhood became separated from East Jerusalem, pregnant women must pass checkpoints close to birth time to deliver in a hospital located in Jerusalem. We aim to explore political determinants of RH in East Jerusalem, in particular access to maternal care, through testimonies of mothers and fathers living in Kufr 'Aqab.

Background to the study
Political conceptualisations of reproductive rights The fourth International Conference on Population and Development (ICPD) held in 1994 conceptualised reproductive rights as: " … the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children … " [ 1 ,p.104] This was a crucial step in shifting focus from societal levels of population regulation to the well-being of couples themselves, particularly women. However, experiences of women in contexts of colonialism, conflict and structural injustice/racism point out the need to further consolidate political determinants of women's reproductive rights in these contexts. [2][3][4][5][6] Expanding on how political factors affect experiences of RH is essential to how we think of reproductive rights. In response to historical and present transgressions on RH, activists working with women of colour in Canada and US coined the term "reproductive justice" focusing on three elements: the right to have an abortion, the right to have children, and the right to parent those children. 4 Adding the second and third rights better accounts for reproductive oppression of Native/Alaskan, African, Latin, and Asian American women, 4-6 such as forced sterilisation 11 and sexual violence. One definition of reproductive justice as "the complete physical, mental, spiritual, political, social, and economic well-being of women and girls" [ 6 , p.20] allows for inclusion of race-and class-based structural inequalities these communities face today. Examples include environmental injustice, drug policies, access to health care, incarceration, and poverty. 4 Ecological views of RH are consistent with local understandings: a study on women's perception of RH in three poor communities around Beirut 12 found good health, both mental and physical, to be of central importance. General well-being (freedom from disease and stress) during pregnancy and motherhood, as well as the ability to have and raise children were part of many women's understanding of RH. Other elements included family planning, good marital relations, and economic status. Whereas the ICPD definition of reproductive rights accounts for the effect of Israeli occupation on certain reproductive behaviours like fertility, 13 it ignores other important links between RH and the political context of the occupied Palestinian territories.

RH in the occupied Palestinian territories
The link between Israeli occupation of the occupied Palestinian territories (oPt) and women's RH is most evident in diminished access to health care during times of heightened violence. In the last bombardment of the Gaza Strip in 2014, access to RH services and their availability were severely affected due to closures and overload of hospitals with treating war-related injury. Consequently, pregnancy complications, preterm deliveries, neonatal mortality, and maternal mortality increased during that period. 14 In the West Bank, barriers to health care are largely related to closures and military checkpoints controlling movement within and between Palestinian cities and villages. This leads to reduced access to antenatal and postnatal care for pregnant women. More so, restrictions on mobility caused an increase in induced and home deliveries and deliveries at checkpoints; 15 one study found that: " … 10% of pregnant Palestinian women were delayed at checkpoints every year from 2000 to 2007, while travelling to give birth in hospital. These delays resulted in 69 births, and 35 infant and five maternal deaths at the checkpoints". 16 Crossing checkpoints is unpredictable and can take from a few minutes to a few hours; sometimes they are closed for a few days. 17 These military posts are also hotspots of violence varying in form and intensity, ranging from verbal/bodily confrontations between Palestinians passing through and soldiers 18 to full-blown aggression with young Palestinian men throwing rocks/Molotov and soldiers shooting tear gas, rubber, and live bullets.
Biopolitics in East Jerusalem: Physical barriers and "centre of life" policy Pregnancy and birth of women living in Kufr 'Aqab are governed by two instruments of biopolitics: physical barriers that regulate access to the city (the separation wall and checkpoints) and discriminatory residency laws governing Palestinian residents of Jerusalem ("centre of life" policy and S88 "permanent residency" status). After Israel occupied the West Bank in 1967, it divided Palestinians into two groups: 7 individuals residing in East Jerusalem were given "permanent residency" (informally known as Jerusalem ID) and Palestinians in all other areas were given what is now known as the Green ID (in reference to the colour of the document cover). Israel illegally annexed Jerusalem and subjugated permanent residents to its jurisdiction and holders of Jerusalem ID are the only group that can live and work there. 8 Holders of Green ID living in Gaza Strip are the most isolated and suffer from most restrictions on movement, which includes very limited or no ability to leave Gaza Strip including visits to the West Bank. 19 Moreover, the blockade on the Gaza Strip also prevents all Palestinians from the West Bank from visiting the Gaza Strip except under special conditions. Holders of Green ID living in the West Bank have more mobility, but have limited or no access to East Jerusalem since its complete separation from the rest of the oPt in 2000. 20 Throughout the paper, we will use the locally used name of West Bank ID holders (WB ID) to differentiate between holders of Green ID who live in the West Bank and those living in the Gaza Strip. Under certain conditions, WB ID holders can apply for permits that enable them to pass through checkpoints and enter East Jerusalem (it is possible for residents of the Gaza Strip to apply to permits to the West Bank, but it is extremely difficult and rare). Permits are temporary, ranging from one day to a year (overnight stay is not permitted) and are given for specific purposes including work, health appointments, religious tourism, and business. 21 Since Israel's indefinite suspension of "family unification" processes in 2003, holders of WB ID may no longer obtain permanent residency through marriage. 21 Palestinian WB-Jerusalem ID couples used to be able to live together in East Jerusalem through a gradual process starting with WB spouse obtaining a permit to live in Jerusalem, followed by a "temporary resident status" and then "permanent residency". Now, living in East Jerusalem is no longer an option for these families as WB ID holders are prohibited from entering Jerusalem without permits.
The second biopolitical instrument is Israeli laws related to permanent residency. The "centre of life" policy, introduced in 1995, required permanent residents to continuously prove they reside within Jerusalem as defined by the Jerusalem municipality. 22 Jerusalem ID holders are liable to lose their right to live in the city even if they have lived there all their lives. Kufr 'Aqab has attracted mixed WB-East Jerusalem couples because it is a neighbourhood of East Jerusalem that remained accessible to WB residents after the construction of the wall. This neighbourhood enables Palestinians with Jerusalem ID and WB ID to live together while simultaneously fulfilling "centre of life" policy. 9,10 Biopolitics in East Jerusalem: Politicisation of pregnancy and birth Residents of Kufr 'Aqab with Jerusalem ID face a major obstacle in relation to pregnancy and birth. Israeli discriminatory policies targeting Arab residents of East Jerusalem begin "literally at birth" [ 7 ,p.545]. While children of Jewish residents of the city are automatically eligible to live in East Jerusalem, 7 Palestinian children's eligibility for residency is contingent upon fulfilling several conditions. Palestinian babies who have at least one parent with a Jerusalem ID must be born in a hospital located in Jerusalem to be able to apply for Jerusalem ID several years later. Although birth in a Jerusalem hospital does not guarantee Jerusalem residency, it is a first critical step in starting the process. Through these restrictions, pregnancy and birth become spheres in which Israel practices biopolitics. A feminist study by Shalhoub-Kevorkian concludes: "Studies of pregnant women and birthing women worldwide point to the importance of health, basic economic wellbeing and social and psychological support as main factors affecting women's welfare. The particular conditions of Palestinian women in the oEJ [occupied East Jerusalem] demand that we also include in the assessment factors such as militarization, bio-political ideologies and socio-legal modes of eviction as crimes against women, similar to studies conducted in South Africa and in states vested in population control". [ 2 ,p.1201] Policing of where Palestinian families can live, travel, and give birth are all forms of biopolitics that serve to control the Arab population in East Jerusalem. The boundaries of East Jerusalem, for example, have been redrawn by the separation wall to exclude highly populated Palestinian areas while including less populated land. 7,9 The "centre of life" policy caused over 14,000 individual residencies to be revoked since 1967, 23 justified by Israel as mostly due to failure of those involved to prove they live within Jerusalem municipality boundaries. According to Jefferis, the L Hamayel et al. Reproductive Health Matters 2017;25(S1):S87-S95

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"centre of life" policy is " … one of the most detrimental policies by which East Jerusalemites are rendered stateless … " [ 8 ,p.96]. Comparing privileges afforded to Jewish residents of East Jerusalem in terms of residency and birth highlights discriminatory aspects of Israeli laws. Palestinian families who may have lived in Jerusalem before Israel was established in 1948 became "permanent residents" whereas Jewish residents who may be recent immigrants receive full benefits of living in the city and the ability to almost unconditionally pass that to their children. 7 We focus in this study on how biopolitics in the form of checkpoints and residency affect access to maternal care for Kufr 'Aqab residents. The aim is to elucidate deeper understanding of the impact Israeli policies have on pregnancy and birthing experiences of Palestinian women and men in East Jerusalem, and furthermore, to examine these findings in the light of current definitions of reproductive rights.

Methodology
The paper presents a subset of findings yielded by a larger study on family life in Kufr 'Aqab (for full study see Hammoudeh et al 24 ). We utilised a basic qualitative research design in which we developed a semi-structured interview schedule. The RH section asked women about their experiences in accessing health care, focusing on pregnancy and birth. Men were asked about their own experiences in relation to their wife's and included for example, their access to the hospital during the time of birth. The sample included 27 women and 20 men living in Kufr 'Aqab and participants were recruited through snowballing. Interviewees made initial contact with their acquaintances who were then contacted by the first or second author. Use of snowballing was necessary to ease suspicion people may have about strangers collecting personal information in that area. 24 Nevertheless, we succeeded in obtaining a diverse sample (see Table 1). Fieldwork was conducted between October 2013 and August 2015 and data collection continued until saturation. Ethical approval was provided by Institute of Community and Public Health Research Ethics Committee at Birzeit University.
Interviews were conducted by the second author and were transcribed by hand by the first author. Both of us are trained in qualitative research and have extensive experience with collecting qualitative data in the oPt. We are both Palestinian females and are native in Arabic, the language in which interviews were conducted. Our identities facilitated interviews with women and made it possible to meet in their homes. We met interviewees in places comfortable to them including homes, workplaces, and coffee shops. Before each interview, we explained the purpose of the research, the right of the interviewee to refuse participation, or end the interview at any time. We also clarified the measures we took to ensure confidentiality. Participants then indicated orally whether they agreed to participate in the study.
Hand-written transcripts were transcribed into digital form in Arabic and translated into English by the first author. The second author re-read all transcripts and translations for quality and accuracy check. Any disagreements were discussed and resolved. Thematic analysis was used: the first and second authors read and re-read interviews until themes and subthemes gradually emerged. Descriptive categories were first created based on broad themes, and further developed into sub-categories through comparative analysis. Each new interview was summarised and parts were sorted into existing or new categories.

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Reliability and validity of the findings were controlled via data and investigator triangulation: we collected data from several sources; in addition to interviews with residents, we interviewed community informants and experts. A form of investigator triangulation was discussion of findings with colleagues who conducted research on East Jerusalem. In this article, we present original quotes from participants to support the validity of our findings. All identifiable information has been removed from quotes and pseudonyms are used to assure anonymity. Several testimonies were excluded from this analysis due to interviewees not having children, or men/women who had children before relocating to Kufr 'Aqab or before the segregation of the neighbourhood (Table 1). Three themes emerged out of the remaining interviews: experience of pregnancy and barriers to maternal care, social separation and isolation at time of childbirth, and notions of resistance. Quotes that are particularly affective or illustrative were chosen to support the themes.

Findings
Experience of pregnancy and barriers to accessing health care Women experienced heightened anxiety and fear during pregnancy for two reasons: crossing checkpoints while pregnant and having to deliver in a Jerusalem hospital. Going to Jerusalem in general was very stressful for all women because of checkpoints and more so during pregnancy. Many women crossed checkpoints regularly during pregnancy to visit family and most of them to seek prenatal care in Jerusalem. Registering beforehand in the hospital where delivery was planned is obligatory and required women to have several appointments, increasing in frequency towards the end of pregnancy. Regular crossings of checkpoints inevitably meant some exposure to violence during the commute: "A soldier was going to hit me once while I was pregnant because I [verbally] challenged him at a checkpoint. I had just come back from visiting my mom in Jerusalem and the checkpoint was closed. Everyone was pushing and there was tear gas. I said I was pregnant and my son was waiting for me at home but he wouldn't let me through. The others [Palestinians waiting to cross] warned me to stay away and said that he has hit women before … .The moment he turned his head, I passed and he started shouting and pulled my clothes". (Aseel, in her thirties, female Palestinian, Jerusalem ID) From Aseel's testimony, we could tell this incident happened several years ago, at Qalandia checkpoint, the main one regulating entrance to Jerusalem from Kufr 'Aqab. Pregnant women are less likely to have direct contact with soldiers now since these days they check documentation from behind a glass window. However, unpredictable waiting hours and closures remain part of the experience. Moreover, at Qalandia checkpoint, confrontations between soldiers and young Palestinians occur at least weekly. The stress of checkpoints was expressed by one interviewee who recalled having a miscarriage immediately after crossing and made a connection between the two. However, the largest fear was related to getting stuck at a checkpoint on their way to give birth in a hospital in Jerusalem: Interestingly, women with WB ID reported more fear of giving birth at a checkpoint than women with Jerusalem IDs. This is possibly due to Jerusalem residents being more used to crossing checkpoints as they have been doing so before getting married. Alternatively, women with WB IDs are more likely to have limited or no access to Jerusalem. If she has no permits, delivering in a Jerusalem hospital is extremely difficult: "We were newly-wed, it was my first pregnancy and I was in my eight month. I sneaked into Jerusalem to my in-laws' house. I was 'illegal' for a whole month, but worse than that is that I felt like a stranger. I mean, we had just got married and my husband was working in the north and would come only once a week. And of course, my mother couldn't reach me. All of this for the sake of ensuring birth in the right hospital. I really felt like I was in prison. My mental health deteriorated at the time". (Natasha, in her thirties, female Palestinian, WB ID) Natasha resorted to tahreeb ["smuggling" of goods and here the process of Palestinians with WB ID crossing into Jerusalem without a permit] to make her baby eligible for permanent residency.

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The second person with WB ID in our sample had a permit at the time of birth but her family was not able to visit her in hospital, which is the custom for close family members. The third woman seized the opportunity of her mother and siblings getting a permit on the basis of religious holiday by requesting that the doctor induce her birth so her family could be near. While women could avoid checkpoints by delivering in the adjacent city of Ramallah, barriers to accessing the hospital and the diminished social support resulting from it are politically determined. This is also evident in women's preference to deliver in Jerusalem over a hospital located in Kufr 'Aqab; one that can provide the necessary documents for registration of the newborn. The hospital was not available for all women at their pregnancy, since it was closed and reopened recently. Nevertheless, most interviewees expressed concern that delivering there would jeopardise registration in the future.
Separation and isolation at time of birth For many, it was husbands who needed a permit to enter Jerusalem because of having WB IDs. This theme reflects stories of those couples from the perspectives of both women and men. Some of the men had temporary permits which meant that they could accompany their wife only if birth took place between certain days or hours: "I can only attend the birth if it happens between 7 am and 7 pm because that is what my permit allows. Outside of these hours, she will have to go alone with her mother. Even if she gives birth at 6 pm I wouldn't be allowed to enter and won't be with her. Imagine if you wouldn't be able to attend the birth of your children, how would you feel?"(Mohammad, in his twenties, male Palestinian, WB ID) Other men in the study had no access as they were denied permits. One woman described how her husband only got to see their children several days after they were born. Another father bitterly recalled the day his wife gave birth. After a check-up at a Jerusalem hospital, Kareem went home to renew his permit, leaving his wife at the hospital in accordance with the doctor's recommendation: "She was seven months pregnant at the time. She had complications and needed to deliver right away. She called frantically and said she needed to go into an operation. It was 10:00 pm, and my permit had expired at 7:00 pm. I couldn't get in … the most I could do was pick up her sister and drop her off at the checkpoint … I sat in the car and began to cry. It was one of the very few times I've cried in my life. It was the worst moment. I kept saying: Why me? Why now? It was a horrible feeling. My sister-in-law's husband was able to be there and I, her husband, could not be there". This separation has not only psychological, but also practical consequences, especially in relation to postnatal care. One woman described having to cross checkpoints for months following delivery as her newborn had complications and needed medical supervision. She resorted to the help of her brothers to drive her back and forth as she was not familiar with that part of the city. Kareem also described how his wife had to drive with stitches to the hospital in Jerusalem where their newborns were incubated, because his permit does not allow him to drive.
Notions of resistance By force rather than by choice, interviewees acted in ways to regain control of their bodies and lives. Some of the stories previously mentioned can also be seen from a different perspective: women who resort to smuggling themselves, inducing birth and disobeying soldier's commands at the checkpoint are instances of resistance that reverse power dynamics. These are ways women acted on opportunities or gaps within oppressive Israeli policies to achieve their aims and desires. Interviewees also spoke of larger ways in which they asserted themselves as active agents within the larger systems of control and discrimination forced on them. Central to their determination to give birth in a Jerusalem hospital despite its consequences for experience of pregnancy and birth is passing the permanent residency to their children. The following quote from Kareem, whose story we included in the previous theme, was chosen because of his ability to articulate a sentiment expressed by almost all the people interviewed: S92 "It's a struggle, they fight us and we fight them back with their own law because it's the only weapon we have. A lot of emotions are involved in this in addition to material, social and psychological pressures. The national aspect gives me motivation to endure. Others resist with guns, but I personally can't do that; and so this [maintaining wife's residency and passing on to the children] is my method of resistance". (Kareem, in his thirties, male Palestinian, WB ID) Maintaining residency, although a more general concept that includes larger practices, also runs at the core of birthing and reproduction, since giving birth at a Jerusalem hospital is the first step in getting children a Jerusalem ID.

Discussion and conclusion
Research from contexts of colonialism and with communities experiencing systematic discrimination call for consolidating the link between reproductive rights and political determinants of RH. Our study with residents of Kufr 'Aqab confirms this. Our findings show that the militarisation of everyday life and biopolitical instruments of state control through checkpoints, regulation of movement, and laws surrounding residency create a heightened sense of fear and anxiety during pregnancy. Fundamental concerns are exposure to violence during pregnancy, fear of giving birth at checkpoints, and barriers to reaching a hospital in Jerusalem. Furthermore, the women in our study had diminished social support during pregnancy, at the time of birth and the months after through separation from husbands or relatives. These stories confirm findings by Shalhoub-Kevorkian 2 who interviewed women in East Jerusalem. In her study, half of the women restricted their movement to avoid checkpoints and other kinds of political violence. Thirty five percent reported being disconnected during pregnancy or at time of birth from their families or their husbands due to checkpoints. Testimonies in our study add to existing literature of RH in the oPt by showing these experiences from the point of view of men who were unable to accompany their wives to the hospital and support them in the months after. These findings must be understood within the larger context of population control carried out by Israel against Palestinian-Arab residents of the city. [7][8][9]21,22 Discrimination becomes evident when comparing barriers permanent residents face to privileges and freedoms afforded to Jewish residents of Jerusalem in relation to movement and birth. Participants' awareness of the political context was central to their motivation to overcome barriers to delivering in a hospital located on the other side of the wall. This was explicitly stated by almost all participants in the study. In the words of Shalhoub-Kevorkian, women in East Jerusalem " … find new ways to subvert colonial oppression and become more visible agents of liberation" [ 2 ,p.1202]. Through enduring extreme conditions to deliver in a Jerusalem hospital, residents of Kufr 'Aqab transformed everyday structures of oppression into sites of resistance. By doing so, they reclaimed aspects of their lives intensely regulated by the state: pregnancy and birth.
The definition of reproductive rights as " … the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children … " [ 1 ,p.104] does not adequately capture political determinants of access to maternal health for the residents of Kufr 'Aqab. A reconceptualisation of this definition to fit the East Jerusalem context would include the right to a pregnancy that is free from political violence, anxiety and fear, the right to freely choose place of birth, and the right to access social support networks.