Thursday, August 19, 2010
In Saudi and Elsewhere, Breastfeeding is Best--Unless It Isn't: Part I A Recent Saudi Thesis and Book
The timing of this post was triggered by an Arab News article, and then a post by Susie of Arabia and the comments there. This has been a topic of professional interest for a long while, and in a number of variants. It is also a topic of personal interest, not the least because of the challenges around breastfeeding for friends and family, both Muslim and non. It is of course a highly personal topic generally, and one that invokes strong feelings and opinions. It is also a topic that involves social pressures, secret feelings of great failure and guilt, and suffers a number of misconceptions.
I would like to address Dr Modia Batterjee's, a Saudi breastfeeding advocate's, work, which is featured in both the article and the post, first. Following that I will address the topic of breastfeeding, bottle feeding, and formula feeding more broadly in Part II, "Breastfeeding vs Bottle vs Formula". In Part III, "Formula Feeding Without Guilt or Shame", I will focus on making your own choices and enacting them.
I have read the available excerpts from the book, and I have read in detail Dr. Batterjee's doctoral (DHA--Doctorate of Heath Administration) thesis on which it is based: A Phenomenology Study Examining Partial Breast-Feeding in the Kingdom of Saudi Arabia (available in full through university and other libraries which have access to Proquest Dissertations). While the thesis has an impressive reference list, if I were an external reviewer for the thesis defense, I would have a number of concerns. As they are rather standard, I assume they were addressed before the thesis was accepted. However, since they do not appear in the published thesis, they obviously were not required revisions before the thesis was finalized for acceptance, submitted, and published as a final version, and the degree granted. I would have asked that those revisions be made before the thesis was passed.
My concerns are both with the substance of the thesis and with the ethics requirements of how it was conducted, which I will address generally rather than citing chapter and page number as I would in a defense.
The Substance of the Thesis/Book
In terms of the substance of the thesis, I have concerns that the literature review, while extensive, is biased by the researcher's pre-conceived notions as a certified lactation consultant, and daughter of a breastfeeding activist, a bias which was insufficiently addressed for this type of research (qualitative-experimental phenomenology). Often in the review research done in a variety of countries under diverse conditions is conflated with the situation in the whole of the KSA, and the evidential weight of the studies themselves is never addressed. These are generally used to buttress the argument that formula feeding is devastating to infant health, and rampantly dangerous to the well-being of Saudi babies and society.
While the counterarguments are addressed, this is done in an overly perfunctory manner. In particular, the issue of women being unable to breastfeed is restricted to narrow biological conditions only, and those largely limited to breast cancer, mastectomy, chemotherapy, and HIV/AIDS. The medical studies cited are insufficient to address these adequately.
The research design is very narrow even for a qualitative study. While the number of subjects interviewed (20) is adequate for this type of study, there is no "control group" or group of women practising other forms of infant feeding, nor from anywhere other than Jeddah, nor from anywhere else in Jeddah besides the Al-Badiyah Center, which is described as a non-profit, but draws educated women who have been reading about breastfeeding and are wanting to breastfeed. The Center also has a store that sells breastfeeding aids and books. These details are not fully elucidated in the thesis, although the demographics of the women, and their self-referral are. These are important considerations as the study's purpose is to elucidate the reason for partial breastfeeding in the Kingdom of Saudi Arabia, as both the statement of purpose, and the title of the thesis declare. In the book, the generalization of the results based on these 20 women in one centre in Jeddah is expanded to "the Middle East".
The interviews, 3 of them, are described at one point as "structured". In that case one would expect an Appendix with a detailed set of questions which were used. In fact it seems to have been "semi-structured", in which case one would expect an Appendix with a list of general questions, and cue questions for the interview. There are neither. There is a questionnaire, which was completed prior to the interview and confirms the details of the partial breastfeeding. In fact rather than structured, or semi-structured, the interviews seem open ended, as there was one general question for each of the 3 interviews, basically: background, what the mother does currently, and why. These are stated in the methods chapter of the thesis. In fact at another point in the thesis it was stated that the interviews were open-ended.
However, based on my interviewing experience and that of a Jordanian PhD student in her home country, one question would not elicit much information without a lot of prompts, even though the culturally appropriate tea and sweets were provided. Perhaps this researcher is a better interviewer than my student, but there is no interview experience detailed for her, only that she did lactation consultations at the Al Badiyah Center. My student was trained and re-trained by an expert (not me) in the particular research interviewing technique for her thesis, and she modified the method further to adapt culturally to the Jordanian interviewees--all of which is detailed in her thesis.
Results, Analysis, and Conclusions
In this thesis there are few excerpts from the interviews in the results and analysis sections, which is unusual for a qualitative method where anonymous excerpts usually form the bulk of the results and analysis sections--particularly when the interviews are semi-structured or open-ended. The analysis makes claims not supported by the evidence given, at least in the thesis, whether it is in the full interview transcripts or not. These claims are generally supportive of the hypotheses of the thesis, but are not only angled towards it, they are overgeneralized, much like the literature review.
In the analysis, as well as in the literature review, the whole of the Saudi situation, and the broader context in which the switch from breastfeeding to formula feeding occurred is not given due consideration. For example, the time period, the 70's to the present day, corresponds not only with formula company propaganda and rising Saudi incomes, but with increased education and professional opportunities, 2 factors which universally decrease breast feeding, both initiation and maintenance. Also there are many other factors aside from formula feeding to explain increased morbidity and mortality for Saudis as a result of obesity, diabetes, and hypertension, namely more sedentary lifestyles, more Western junk food, more fast food outlets among others--none of which are mentioned even to refute them.
The conclusions are largely narrowed to only one of the findings, that of a lack of support in Saudi for breastfeeding focused on insufficient breast milk, resulting in supplementing with formula. This corresponds to the original hypothesis. A prominent, and interesting finding, like the exact social dynamics of the discouragement for breastfeeding is largely ignored. The narrowed conclusions lead to the recommendation of increased institutional support for breastfeeding, perhaps in keeping with the field of health administration, but also in keeping with the need for breastfeeding centres like the Al-Badiyah Center which is the only one of its kind in the Kingdom.
The Ethics of the Thesis/Book
Introduction to the ethics of human subject research
The ethics of a research project are only as good as its science. The first step in an ethics review of a research project involving human subjects is to assess the science: Is this question important enough to do the research? Is the science sound? Is the method scientifically safe for the research subjects? The second step is the ethics of the study itself: Does it meet the established norms for studies of human subjects? Do the subjects give their informed consent, ie does a mentally competent subject agree to participate with full knowledge and understanding of the procedures of the study, the risks, the alternatives, the option to withdraw without penalty at any time; is free from coercion (including by overly generous monetary compensation; or a therapeutic or dependent relationship with the researcher which is thought to lead subjects to feel they should agree to the study to please the researcher), and are they voluntary (unlike for example military recruits, political prisoners, etc). Are the subject's privacy and confidentiality during the research and in storing, reporting, and dissemination of the results preserved?
Social science research involving human subjects is not as rigorous about ethics as is medical research, although it is supposed to be and is held to be so in Canada (much to the chagrin of many social science researcher colleague, who complains to me about this--feeling that their field has other ways of being ethical). As this thesis in health administration is based on interviews with individuals who are clients, or receiving education and counseling, about themselves, and in a centre created for that purpose, I would expect the ethics of the research to lean on the side of health standards, like those for human subjects research in medicine, nursing, physiotherapy, occupational therapy, etc, rather than some other form of human subject research, like an ethnographic study of the concept of schizophrenia based on observation of an isolated tribal village's responses to the decompensating "village idiot or fool, or odd person".
In some ways the normal ethical standards for this type of research were met in this thesis on breastfeeding in the KSA, while other aspects seem not to have been, or else were not required, or not detailed in the published version of the thesis, which is usually the one that was defended plus any corrections required prior to the degree being granted. The fact, that some were, does make me wonder more about the rest. Based on information in the thesis, in the book excerpts, on the centre's website, and in the news article and the post, I would have the following concerns at a thesis defense.
Ethics of the Research Method
My greatest concern about the ethics of this thesis relates to the site where the subjects were recruited and interviewed, the Al-Badiyah Center. As mentioned in the book, this centre was created by the researcher and her parents during the time of her doctoral studies. The 3 are co-owners, the researcher's mother is the administrator, and the researcher has worked on the premises as a consultant and counsellor. This information is not provided in the thesis. It should be, and the methods should include what measures were taken to distance the research from this ownership and administration, in order to ensure a lack of conflict of interest, or even the appearance of one.
In a similar vein, although the required permission from the research site is included in an Appendix as it should be, the signature of the Administrator is that of the researcher's mother, using her maiden name only, whereas she is normally identified online by her maiden name hyphenated with her married name, that is the same surname as the researchers. To be ethical a research project must both be so, and appear to be so. In this instance, I am left wondering if the university officials from the researcher's superviser on up were aware of this potential conflict of interest. I hope so.
This is the type of information that should be addressed by the University of Phoenix Institutional Review Board (IRB) for research proposals involving human subjects. Normally it is stated in the thesis that such a review was done, permission granted, and the IRB letter included in an Appendix. This does not seem to be the case for this research and dissertation.
The "Introductory Letter" about the research study, which is included in an Appendix, and which is part of the informed consent process--to give potential subjects an idea about what the study involves--is in fact overly academic, rather than showing the potential subject what is involved from their perspective,eg. how many interviews, how much time is involved, and the name and contact information for the superviser, with encouragement to contact the same with any questions.
Some of this information is included in the "Informed Consent and Confidentiality" Form. Yet there are other confusing aspects of this form even though it does have some very good information about confidentiality protocols. The researcher is identified here only as a "Doctoral Learner", an odd term, without the degree type mentioned; the study purpose is stated as involving Jeddah not the KSA; the 3 items dealing with the reporting of research results and confidentiality somewhat contradict each other. Getting back to the issue of the superviser and the IRB neither is mentioned, and the researcher is identified as an "independent researcher" as well as a "Doctoral Learner at the University of Phoenix. The only time I have seen this used in academia is when the researcher is not affiliated with an institution, or has not submitted the research protocol to the IRB for approval prior to starting the study, as should happen, or didn't receive the approval.
Finally, although it is much to the researcher's and her superviser's credit that the acknowledgments include by name all those who helped with the academic work of the thesis, for a doctoral student, the researcher had an unusual number of editors, a life coach, and translators/transcriptionists/research assistants. The Al-Bidayah Center is not mentioned, nor are any scholarships, or other funding, as they should be.
As I mentioned at the beginning, I am sure the University of Phoenix, Arizona would adhere to contemporary US standards of ethical research involving human subjects, and methodological norms of social science research, so I am assuming these concerns were addressed. The issues should have also been formally re-dressed in the thesis itself before it was published. The book illuminates some aspects, and may do others in the full version which is not yet available to me. However, the book is aimed at a non-academic audience, and is more of an activist stance, in keeping with the researcher's lactation training, carrying on the family tradition of advocacy (the opening is by her mother), and their ownership of a breastfeeding centre.
Please share your comments, thoughts, impressions, and experiences.
Men and women, mothers and non, are all welcome to share their opinions.
Please be sensitive to the choices of others, as I know regular commentators are, and expect all readers/commentators will be.