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RAMALLAH, West Bank (Reuters) - "Fatma", a mother of twins with a demanding workload, was distraught to discover she was pregnant again. Her doctor agreed to perform an abortion, she says, only after she promised to pretend the procedure had been a medical emergency.
"He felt sorry for me and told me, 'If someone asks you how you ended up having an abortion, I will be in trouble and will lose my job, so say you were hemorrhaging at the time,'" said Fatma, who lives in the West Bank.
"He did the abortion for me - the first time, the second time and third time," she told Reuters, speaking on condition her real name not be used as she had never told her husband.
For women seeking abortions in the occupied West Bank and Gaza Strip, where Palestinian law strictly limits the procedure, the choice is stark: have the baby or terminate the pregnancy by using ruses, risky back-alley methods or even turning to neighboring Israel, where the laws are far more permissive.
Women's rights campaigners rue the ban but decriminalization looks unlikely. Conservative customs guide much of Palestinian society and parliament has effectively been suspended since 2007 because of factional disputes, making it impossible to amend or pass new laws.
According to the Palestinian Health Ministry, doctors are permitted to perform abortions only when pregnancy endangers the mother's life, but not if it is a peril to her mental health.
When fetal impairment is detected, an abortion can be performed if both parents consent, but terminating a pregnancy that resulted from rape or incest is banned, the ministry said.
Palestinian authorities declined to give figures for how many abortions had been approved or how many people had been prosecuted for violating the law. Anecdotal accounts suggest such sanctions are rare, but the fear of repercussion and violating taboos keep many abortions covert.
According to Wafa Muammar, head of the Palestinian police family protection unit, a woman who has an illegal abortion could face 1 to 3 years' imprisonment.
That may be reduced to 6 to 12 months in cases of "shame-preventing" termination of pregnancies that resulted from incest or rape, Muammar said.
The same reduction applies if a woman is threatened with a so-called "honor killing" for getting pregnant outside marriage.
Unlicensed or back-alley abortionists can also get 1 to 3 year prison terms, or 5 to 15 years if the woman dies from the procedure, Muammar said, adding that if the practitioner is a doctor, he or she could be jailed for an additional 3 years.
"If the woman herself does the abortion, she will suffer a penalty, as will anyone who helps her," Muammar said.
Even opting for emergency contraception such as "morning-after" pills is taboo. Some pharmacists have been known to dispense the pills with no questions asked.
"Samira," another Palestinian woman who spoke to Reuters on condition of anonymity, said she found a sympathetic pharmacist away from her home town to help a friend prevent a pregnancy.
"I told him about the woman, that she has 10 kids and is not feeling well," Samira said. "I told him, 'You are safe, I'm not even from this area and your name will never be mentioned.' He said, 'Okay, I trust you, here you go, here's the medicine.'"
Amina Awedat, director of the non-profit Palestinian Family Planning and Protection Association (PFPPA), said that while she respects Palestinian law, she wanted to see "safe services" become readily available for women who want abortions.
"Ultimately, unsafe abortions prove costly because when women start hemorrhaging and have to go to hospital, the cost of getting the abortion and recovering from unsafe abortions is higher," Awedat said.
For some women, the motive for an abortion is fear of paying the ultimate cost - being killed by a male relative to preserve the family's "honor".
For now, some Palestinian women are turning to Israel, where abortion is available once approved by a medical committee. Palestinians living in East Jerusalem, which Israel counts as part of its jurisdiction, have free access to Israeli hospitals.
Israeli government data on abortion recipients do not distinguish between East Jerusalem Palestinians and Arab citizens, who make up 20 percent of Israel's population.
The most recent Central Bureau of Statistics data, from 2012 and 2013, found that around 85 percent of recipients were from the Jewish majority, and 15 percent - 2,600 to 2,800 cases annually - either Israeli Arabs or East Jerusalem Palestinians.
A CBS official, citing anecdotal information relayed by hospital registrars, said 9 Palestinian women from the West Bank or Gaza had abortions in Israel in 2012, and another 6 in 2013.
Even that small number appears to have trailed off recently.
Dalia Basa, an Israeli government official in charge of arranging entry of Palestinians for medical treatment, said she was now aware of around one abortion case a year.
"Usually these women turn to Israel because of 'family honor' sensitivities which require discretion," Basa told Reuters, meaning pregnancies that resulted from illicit unions.
She said that in such cases the recipient's application to have the abortion in Israel is generally handled by human rights groups or relatives in East Jerusalem or Israel's Arab sector.
Writing by Dan Williams; Editing by Jeffrey Heller and Philippa Fletcher