Wet-nursing as a new strategy for orphan care in Saudi Arabia

Abstract

Background

Saudi Arabia hosts more than 150 charitable institutions dedicated to vulnerable groups, such as orphan care associations that provide orphaned children with food, clothing, housing, and other care until they reach adulthood. The Al-Wedad Society for Orphan Care (ASOC) in Saudi Arabi operates a wet nursing program in which Saudi mothers breastfeed orphans in their care under specific conditions and circumstances. The program is intended to not only help the orphans survive and receive the psychological and nutritional benefits of breastfeeding but also establish kinship between the child and the members of the family providing the wet nursing and so support children’s emotional wellbeing and belonging.

Methods

The ASOC wet nursing program was explored using two methods: content analysis of existing sources, such as documents and archival records, and in-depth interviews with ASOC full-time administrations and professional practitioners (n = 9). Data collection took approximately five months (January 2022 to May 2022).

Results

The study reveals the positive values of wet-nursing as beneficial for both orphans and volunteer wet nurses. The results illustrate that the wet-nursing program has undertaken steps to ensure health and safety requirements of participants. The program elaborates many positives. First, after completing the breastfeeding program, the child becomes a relative of the whole family not only breastfed mother. Second, the breastfeeding could be a solution for many abandoned children dealing with a loss of identity as it gives them a sense of belonging to a family and community. Third, the child feels more secure and confident to interact normally with family members of the opposite sex especially upon reaching adolescence. They can communicate freely with fellow family members with fewer constraints, a greater sense of belonging, and less stigmatization than would otherwise be the case.

Conclusion

This ASOC wet nursing program has been successful in supporting the breastfeeding and legal belonging via milk kinship of children in alternative care families but challenges remain. More research is needed on the impact of programs such as the ASOC wet nursing program on children, alternative caregiving families and societies.

Background

The practice of wet nursing dates to ancient times and involves an infant being breastfed by a woman who is not their biological mother [1–2]. Wet nursing is recommended by the World Health Organization and UNICEF if the milk supply from the biological mother is unavailable or insufficient, especially in emergency conditions [3, 4]. Breastfeeding protects the health of infants, including from serious illness and death and enables normal development [2, 5] and in general, wet nursing is a better option than artificial infant milk if an infant is unable to be breastfed by their mother [6]. In Islamic law, children have a right to be breastfed and this is considered one of the most important children’s rights [7, 8]. The importance of this right is such that if a mother is unable to breastfeed her child, the father is obliged to pay a wet nurse to breastfeed the child [9,10,11]. However, according to Islamic law, wet nursing creates ties of “milk kinship”. Milk kinship is a kinship tie formed between a child and a wet nurse and their families through the consumption of breastmilk, also known as rada [8, 9]. Kinship ties are similar to ties of blood kinship, with the implication that wet nursing prohibits marriage between individuals related by milk [10,11,12]. As described below, the creation of milk kinship also has implications for orphaned and abandoned children being cared for in alternative families.

In many countries of the world, children who are unable to be cared for by their family may be placed in the care of others and adopted so becoming full legal members of their new family [13–14]. Due to cultural and religious reasons, this is not the case in Saudi Arabia, where the “alternative family” (aleayilat albadila) and “sponsorship” (altabaniy) are the standard forms of alternative family care for children. These forms of care are similar to foster care or guardianship as practiced in some other countries in that parents have custody and care of children but not legal relatedness. Saudi Arabian legislation on alternative family structures was first formulated in 1975 and are governed directly by Islamic law [7,8,9]. Throughout the rest of this paper we will refer to this type of as “alternative family care.”

In Islamic countries, lack of legal relatedness for children in alternative family has important ramifications for both children and their caregiving families. For example, once a male child in alternative family care reaches puberty, the mother and other female family members will need to wear the hijab (veil) in front of him as he is non-mahram (an outsider) [15]. From psychological perspective, it is distressing for a child to be treated as not a member of the family in this way. This may be partly why female children are more likely to be accepted in alternative family care than male children in the Gulf States [16,17,18]. However, wet nursing by alternative care mothers can assist in providing a form of legal relatedness. This is because when a woman breastfeeds a child in an alternative family care arrangement on at least five separate sessions, the child religiously and legally becomes a mahram (an insider) to the family by virtue of milk kinship [8–9]. This relationship is not considered the same as if the child were born into the family, the child does not have inheritance rights from the family and does not take the family name however, it still provides legal and social belonging and so is beneficial.

The Al-Wedad Society for Orphan Care (ASOC) was established in 2007 in Makkah, Saudi Arabia, and serves orphaned children by assigning them to preselected foster homes and monitoring their care. In recognition of the ways in which milk kinship can benefit children in alternative family care the ASOC encourages and supports wet nursing by alternative family care mothers. This is a specialized care plan for orphaned children under two years of age and is the first of its kind in Saudi Arabia. Under their wet nursing program, the ASOC prelists and screens families that meet the conditions for nursing orphans. Such families are screened based on the following requirements: (1) they must be Saudi families; (2) the wife should be at least 25 years old at the time of application; (3) the wife should not be above 50 years at the time of nursing; (4) the families should meet certain social, economic, and psychological criteria; (5) the family must pass health and safety checks; (6) the family must pass security checks; (7) the family must pass checks regarding legal breastfeeding in the family; and (8) the family must obtain a nursing license which is a document that says that the alternative care mother can breastfeed.

This study evaluates the impact of the wet nursing program at ASOC on children, nursing mothers, alternative care families, agencies, and communities. The following research questions were asked: What are the positive aspects of the wet nursing program on these groups? What are the challenges faced by the program and its participants?

Methods

This study applied the case study as a strategic qualitative research method to it enables the researchers to gain a holistic view of a study’s topic. As a qualitative method, the case study has been commonly used in social science fields like social work. Taken into consideration case study is useful in capturing the emergent and immanent properties in societies and institutions. From data triangulation (multiple techniques) perspective, the study used two research tools to explore the wet nursing program: content analysis of existing sources, such as documents and archival records, and in-depth interviews with ASOC employees.

After applying for ethical approval, the researcher organized a meeting with the director of the ASOC, where clarifications were exchanged from both sides, following which the study was ethically approved by the research committee at the ASOC (ERSC_2023_4016). Data collection occurred over approximately five months (January 2022 to May 2022).

Document analysis

In total, 624 documents, 38 active files, 176 archival records, and 12 brochures that were relevant to the wet nursing program at ASOC were identified and analysed using content analysis to identify positive aspects and challenges associated with the ASOC.

Interviews

Following the content analysis, in-depth interviews were conducted with all the official professionals who full-time employed by the ASOC (n = 9). The content analysis informed the questions posed to interviewees and pilot interviews were conducted to test the interview guide and interviewing skills before conducting the actual interviews.

Characteristics of interviewees is presented in Table 1.

Table 1 Characteristics of interviewees

The interviews took place at the ASOC, and each lasted approximately 120 min. These interviews included questions related to different aspects of the wet nursing program, as well as the challenges faced by the applicants of the program. Each interview followed the same structured format with questions designed to explore the program based on the study’s objectives. The interviews were transcribed verbatim in Arabic. An informed consent document was provided to each participant before conducting the interview, which clearly explained the nature of the study, stating that participation was not mandatory and assuring participant confidentiality.

After conducting and transcribing each interview, an initial analysis was performed by organizing texts into categories used by the researcher during the interview, writing marginal notes to identify respondents’ primary points, and generating codes for specific themes (thematic analysis). As the analysis progressed, follow-ups were conducted with some respondents by telephone to discuss and confirm that the interpretations of their answers were correct.

Validity and reliability

To validate results in content analysis, the researchers included inter-coder reliability tests, where multiple coders independently code a subset of the data to assess consistency.

The researchers applied strategies to mitigate bias. First, triangulation was used to compare findings from the content analysis with the in-depth interviews data to confirm or refute conclusions. Second, the researchers used mutual checking by sharing preliminary findings or interpretations and seeking feedback from one another to promote self-awareness and to identify potential areas of bias during analysis. The researchers also kept an audit trail, applied peer debriefing and reflexive journaling.

Results

The findings of the content analysis and interviews were consistent with each other. The ASOC documents illustrate that since its establishment in 2007, the wet nursing program has undertaken steps to ensure health and safety requirements of participants. First, the staff select a suitable family that matches the child’s needs. To provide a normal life for orphaned children within the nursing family, the staff require that the child be breastfed by the prospective mother so that the orphan does not feel isolated from family members after puberty. A medical program was implemented to stimulate milk production in women who were not breastfeeding at the time. Mothers unable to bear children and their families achieved their desire to embrace orphan children as sons or daughters through the practice of breastfeeding. After establishing the program, the ASOC obtained legal approval (fatwa) from the Council of Senior Scholars, which states that a child given five full feeds becomes the foster mother’s son/daughter via breastfeeding and is legally related to the family.

The official documents at the ASOC indicated only one definition of breastfeeding rooted in the Islamic perspective. Therefore, the ASOC defines breastfeeding under the title “Family Tree and Kinship Developed through Wet Nurse” (i.e., a woman employed to suckle the baby of another woman). A professional at the ASOC [P1] expressed the following:

If breastfed by a female from any side of the family [five distinct times], the child becomes a relative of the whole family. He or she, for instance, becomes a great/grandchild, a son/daughter and a sibling, cousin, nephew, niece […] by breastfeeding. Thus, whatever is permissible or forbidden for blood-related family members [e.g., marriage] is also applicable to the breastfed person—the only exception is inheritance and name.

This interview confirmed a significant point related to breastfeeding from an Islamic perspective. In Islam, when a woman caring for a child in an alternative family care arrangement (or one of her daughters or sisters) breastfeeds a child in at least five separate sessions, the child religiously and legally becomes a mahram to the alternative care family by virtue of breastfeeding rather than by blood, birth, or marriage. In other words, the child becomes a close relative by virtue of being breastfed by a family member, meaning that they are considered a non-marriageable person in the family.

According to the same documentation, the nursing mothers were each paid a one-off sum of $400 after meeting certain conditions. This payment is a part of the institution’s strategies as a fund to support the voluntarily participating mothers. To breastfeed a child, the woman must be free from infectious diseases and have a good reputation. She needs to prove that she is a nonsmoker and a Saudi (or married to a Saudi husband). Permission from the husband is also required because the child becomes a part of the family. Visits are carried out to ensure that the family and the neighborhood where the family resides is a suitable environment for the child. Some interviews [P2], [P3] and [P4] confirmed that the visit reports are comprehensive and detailed. These reports are part of the professional work of the ASOC, and include a series of conferences. The final decision of the report is then written and signed by the professional team.

Once the child has been fully breastfed on at least five separate occasions by the alternative care mother, the child is given an acknowledgment certificate by the court stating that they are the child of the nursing mother. This official document protects the family and the child from any confusion, especially regarding marriage. According to an interviewee [P5],

Women turn from being wet nurses into mothers, as an affectionate attachment has been formed between the child and the mother in particular, and the whole family in general.

According to the ASOC documents and the interviews with the administrators and practitioners [P4], [P6], [P3] [P7] and [P9], the alternative care family is encouraged to see nursing as a means of enabling the child to be part of that family. In turn, interviewees stated that the child feels more secure and confident to interact normally with family members of the opposite sex upon reaching adolescence. The interviewees indicated that families that breastfed their foster children thus circumvented many barriers in personal communication and interaction with family members, especially of the opposite sex, as non-mahrams. These barriers include Muslim girls needing to wear the hijab and avoid physical contact with outsider males when they reach puberty ( both males and females are taught not to have close relationships with each other outside of marriage). They can communicate freely with fellow family members with fewer constraints, a greater sense of belonging, and less stigmatization than would otherwise be the case.

One of interviewees [P6] believes that both breastfeeding and alternative family care are critically important to Saudi society. The interviewee [P6] stated:

Social welfare for abandoned children and young people, as is shown through the history of Saudi society, has been the center of interest of both formal care via residential institutions and informal care through alternative families. As a matter of fact, none of the Saudi Social Development Plans has overlooked providing care for children and young people through these three approaches. The focus of the alternative family approach has been clearly stated in the last five Saudi Social Development Plans during the last 15 years.

However, study participants described some problems in alternative care for children including related to the naming of children and concern regarding illegitimate status. In Saudi Arabia child in alternative family care must keep their own name or the name given by the official body (MHRSD) which sets them apart from their caregiving family. This practice comes from Islamic law which says that these children should have the same rights as birth children but not at their expense and so they also do not have inheritance rights. Having the surname of the family might result in it being understood that a child, according to Islamic law, has the right to inherit the same amount of money as the biological children. Although it may seem justifiable not to give children the same name as their caregiving family to protect the rights of birth children, there are negative effects. If the child was able to take the name of their family, this would help address issues related to the ambiguous and stigmatized identity that abandoned children and young people may experience.

It was identified that the mistaken belief that illegitimacy is the only reason mothers abandon their children, makes some hesitant to bring abandoned children into their family. Instead, they might prefer to financially sponsor orphans whose parents are known to have perished, rather than abandoned children (i.e., foundlings). According to [P5] at the ASOC, many Saudi families take children from residential nurseries into their care, but once they learn about the child’s past, they become reluctant to continue the process. For those children for whom alternative family care might not be an available option, the breastfeeding of multiple abandoned infants by one wet nurse could enable those children to become siblings through breastfeeding and enhance a sense of identity and belonging between them. There would however, be implications for the wet nurse and her family.

Some professionals at the ASOC [P2] [P8] and [P7] emphasized that an unclear sense of identity and feelings of confusion about oneself are common among abandoned children and young people who have spent a long time in care. Most of the time, these children worry about not knowing where they came from, who their families are, to whom they belong, and whether and how they came to be forgotten and abandoned by their families. Such questions, which often have no clear or convincing answers, lead to a general sense of uncertainty and make it difficult for them to live stable lives.

However, breastfeeding was given the highest priority by ASOC staff in addressing the problems of identity, stigma, and confusion, as well as in minimizing the risk of the adopted person leaving the alternative care family before reaching adulthood. Many interviewees were aware of the reasons prohibiting children in alternative care arrangement from taking the names of the family caring for them and concerned about the need to support children in understanding their situation as they grow and develop. They pointed to a program the ASOC recently introduced named “Kinship Developed through Breastfeeding.” This unique program seeks to minimize the risk of young people feeling alienated and leaving their alternative care family in adolescence by directly and openly addressing the issues of belonging and identity for these children. This includes by increasing their understanding of the kinship bond formed by breastfeeding.

Discussion

This study indicated that programs such as the ASOC wet nursing program could be beneficial for many abandoned children. Based on the analysis of documents regarding the ASOC’s institutional policies, for a child who is cut off from their roots, breastfeeding is likely to give that child a deeper sense of belonging and kinship with the alternative care family. It is not only nutrition but also a form of connection with the mother and the whole caregiving family. We propose the following benefits be considered:

First, after completing the breastfeeding program, the child becomes a relative of the whole family not only breastfed mother.

Second, the breastfeeding could be a solution for many abandoned children dealing with a loss of identity and in need of belonging to a family and community. Education of the child with the “Kinship Developed through Breastfeeding” program is an innovation to encourage this.

Third, the child feels more secure and confident to interact normally with family members of the opposite sex especially upon reaching adolescence.

In general, the study emphasizes the positive values of wet nursing as beneficial for both orphans for their health and emotional wellbeing and alternative care families. This result is in line with other local and global studies [5, 15–16, 19,20,21,22].

Limitations

This study was limited to the viewpoints of view of staff and official documents available at the agency without consulting alternative family mothers or other family members or children or adults raised in alternative family care and wet nursed by their alternative care mother. Future research on this topic should seek to include these important perspectives. This study thus recommends conducting further research on this topic using longitudinal data on children who have received care through a wet nursing program such as that conducted at the ASOC. Evaluation studies conducted by third parties or independent bodies may be the most reliable for exploring the possible positives and negatives of such programs.

Conclusions

The study reveals belief in the positive effects of the ASOC wet nursing program as a unique childcare program in Saudi Arabia. At the forefront of these positives is the attempt to secure these children a normal life (i.e., nutritional, health, psychological, social, and cultural) that was lost due to adverse circumstances as well as belonging in a family. However, the study discloses some challenges, especially those related to identity, stigma, and confusion among abandoned children. Among the largest challenges exposed by the study are the issues of surnames and illegitimacy. More research is needed on the impact of programs such as the ASOC wet nursing program on children, alternative caregiving families and societies.