Health research in a turbulent region: the Reproductive Health Working Group

Abstract

The Reproductive Health Working Group (RHWG) was established in 1988 in Cairo to advance research in the Arab countries and Turkey on the health of women, broadly defined. The paper considers the ways in which the group contributed to global health conversations through three examples of interdisciplinary research that, in privileging local contexts, modified or even challenged prevailing approaches to health and often raised entirely new issues for consideration. The three examples cited in the paper are: (i) the network’s early research on reproductive morbidity; (ii) a broad set of ongoing studies on childbirth/maternal health; and (iii) emerging research on health and conflict. The paper discusses how the RHWG has strengthened research capability in the region, and explores the reasons for the longevity of this research network.

Résumé

Le Groupe de travail sur la santé de la reproduction (RHWG) a été créé en 1988 au Caire pour faire progresser la recherche dans les pays arabes et la Turquie sur la santé des femmes, largement définie. L’article examine les façons dont le groupe a contribué aux conversations de santé mondiales à travers trois exemples de recherches interdisciplinaires qui, en privilégiant les contextes locaux, ont modifié, voire défié, les approches dominantes de la santé et ont souvent soulevé des questions entièrement nouvelles à examiner. Les trois exemples cités dans l’article sont les suivants: (i) les premières recherches du réseau sur la morbidité reproductive; (ii) un large éventail d'études en cours sur l'accouchement / la santé maternelle; et (iii) des recherches émergentes sur la santé et les conflits. Le document traite de la façon dont RHWG a renforcé les capacité de recherche dans la région et explore les raisons de la longévité de ce réseau de recherche.

موجز اامقال

أنشئت مجموعة العمل حول الصحة الإنجابية في العام 1988 في القاهرة للنهوض بالأبحاث في البلدان العربية وتركيا حول صحة المرأة، المعروفة على نطاق واسع. ويأخذ المقال بعين الاعتبار كيف ساهمت المجموعة في المحادثات الصحية العالمية من خلال تقديم ثلاثة أمثلة عن الأبحاث المتعددة التخصصات التي، من خلال التركيز على السياقات المحلية، قد غيرت أو حتى تحدت النهوج السائدة للصحة وغالبًا ما أثارت للاعتبار مسائل جديدة تمامًا. والأمثلة الثلاثة المذكورة في المقال هي: (1) أبحاث الشبكة المبكرة حول الاعتلال الإنجابي؛ (2) مجموعة واسعة من الدراسات الجارية المتعلقة بالولادة / صحة الأم؛ و (3) الأبحاث الناشئة حول الصحة والصراع. ويناقش المقال كيف عززت مجموعة العمل المذكورة آنفًا القدرة البحثية في المنطقة ومستكشفًا أسباب طول عمر هذه الشبكة البحثية

Keywords:

• reproductive health
• women’s health
• interdisciplinary research
• multidisciplinary teams
• research networks
• social sciences
• ethnographic methods
• public health
• Arab world
• Turkey

Introduction

The Reproductive Health Working Group (RHWG) was established in 1988 in Cairo to advance research in the Arab countries and Turkey on the health of women, broadly defined, from a regional perspective. Over its life of nearly three decades, the RHWG has evolved from collaborations among several scholars to a broader and more formalised network of researchers sharing and comparing approaches and findings. The RHWG, as its name suggests, began with a focus on women’s reproductive health, reflecting the local and global discourses on reproductive health and rights in the years preceding the International Conference on Population and Health in Cairo in 1994. This limited focus, however, was debated from the start, and over time, the focus expanded to include women’s health in general as well as men’s lives¹ and men’s impact on women’s health² and to incorporate issues of concern to other biosocial groups, such as adolescents,³ refugees,⁴ as well as menopausal⁵ and unmarried women.⁶

The RHWG is currently governed by a coordinator and regional Consultative Committee consisting of five long-standing RHWG members (who are also active researchers and mentors). The RHWG Coordinator (DeJong) is based in the Faculty of Health Sciences at the American University of Beirut, and Committee members are respectively in Lebanon, Palestine, Syria, Tunisia and Turkey. Its membership is open to researchers and practitioners in the Arab world and Turkey. Members are anthropologists, economists, educators, midwives, nurses, physicians, population scientists, public health specialists, sociologists and from a range of other disciplines. Most members are women, making it unusual in and of itself in the region. RHWG members participate actively in conceptualising, formulating and implementing the group’s current and future objectives. A major event in the RHWG calendar is its nearly annual meeting attended by about 45 participants on average who present research at different stages of development. Approximately one-third of annual meeting participants are new to the group, many newly returned to the region from PhD studies elsewhere.

The RHWG has managed, despite an increasingly divided and conflict-ridden region, to create a generous community of researchers, who explicitly welcome and support junior scholars, offer constructive criticism throughout the research process, and together, provide a collective voice from a region underrepresented and poorly understood in global public health and development debates. A constant through the life of the RHWG has been openness towards the socio-historical embeddedness of health, attention to local lived experience, and the privileging of multidisciplinary research, which allows for alternative ways of knowing about health concerns in actual contexts.

In reviewing the experience of the RHWG, this paper examines what perspective the group brought from the region to global discussions, beyond an already evolving field of reproductive health. It also seeks to address a question of importance for networks in general, such as their perceived value and the challenges of sustainability, as well as those more specific to this network – enduring while remaining relevant to the challenges of everyday life in a turbulent region. After a brief review of its history, three particular themes of research by network members are singled out, and then the final section of the paper discusses how the network operates and contributes to capacity-building in research.

Advancing critical, contextual research

Three decades ago the population and public health fields often had separate objectives and vertical institutional set-ups, and these had a clear effect on research on reproduction. Internationally, research developed an overwhelming reliance on a particular method, demographic surveys, and a focus on the separate objectives of fertility and fertility control, child survival and maternal health. By the late 1980s, feminist researchers and health advocates had challenged these separate and narrow objectives globally, articulated a broad agenda for reproductive health and rights, including sexual health, and contributed significantly to shaping the International Conference on Population and Development in Cairo in 1994. This history is well-documented.^7–11

The first members of the RHWG, researchers from several Arab countries and Turkey, gathered in Cairo in 1988 under the auspices of the Population Council.* At a time when holistic views of reproduction and its links to health were emerging globally, the group emphasised the development of conceptual frameworks to analyse women’s health and rights in the context of regional realities that included poverty, patriarchy, autocratic regimes and neoliberal economic policies. The group sought to conceptualise reproductive health in terms of life trajectories within larger fields of social relationships and adopted the definition:

The ability of women to live from adolescence and beyond with reproductive choice, dignity, and successful childbearing, and to be reasonably free from gynaecological risk and disease.¹²

The RHWG defined its mission as tri-fold: to produce contextual knowledge about women’s reproductive health in the Arab world and Turkey; build local capacity for rigorous research; and to influence policies and practices in the region.¹³ As part of that mission, the RHWG sought to foster innovative and interdisciplinary research that was reflective of regional realities and concerns but also evolved in conversation with global research trends in reproductive health.

Three examples of research innovation are presented in this paper. We chose these three areas as being particularly enduring within the network, but also timely in relation to both regional and global debates. They also illustrate the different modalities in which the RHWG has supported research capacity and encouraged multidisciplinary research of both local and global relevance.

The first one – on reproductive morbidity – represented an integral part of the early group members’ efforts from the late 1980s to set a research agenda, with a deliberate focus beyond the prevailing narrow one on fertility control. This theme, initiated by a study in Egypt, with the specific purpose of taking into account women’s experiences and perceptions of their reproducing bodies, inspired and encouraged a number of specific studies undertaken by different network members in different countries over time. In turn, this group of studies helped to create a sense of cohesiveness of the RHWG.

The second theme – maternal health/ childbirth – illustrates the convening role of the network in bringing together parallel and independent work that had originated in different countries of the region. It emerged out of concern about a missing focus in existing maternal health research at a global level that focused more on high-risk pregnancies. This sub-set of research initiatives on maternal health became part of an independent network on childbirth that remained linked with the RHWG and whose studies are presented annually at its meetings.

Finally, the third theme – violence, conflict and health – was developed spontaneously out of the historical experience of Palestinian suffering, but was sharply brought into focus when violence began permeating almost the entire region in the aftermath of the Iraq wars, Arab uprisings, the conflict in Syria and the immense forced displacement in the region. Researchers and network members conducting individual but mutually relevant studies on this topic found in the RHWG a forum in which to share their common concerns.

Engagements of biomedical with psychosocial: research on reproductive morbidity

The first major research project was an interdisciplinary study initiated in the late 1980s on women’s reproductive health in rural Giza, just outside Cairo, Egypt. The research team included a senior anthropologist (Khattab), a professor of obstetrics/Gynecology (Younis) and an eminent biostatistician (Zurayk).^† The preparations for the study, involving formulation of the conceptual framework, selection of the study site and acquisition of official permits took about a year with the fieldwork taking place during 1989–1990. This period was very valuable, first, in initiating the formation of a truly multidisciplinary research team, and secondly, for getting acquainted with the community. The study relied heavily on ethnographic methods, which underscored the centrality of women’s priorities and perceptions. This was a time when so-called interdisciplinary research was most often biomedical in its approach, hypotheses and methods, with the social sciences playing an auxiliary role at best. The Giza Reproductive Morbidity Study, as it became known, brought a balance and rigour to the research by drawing equally on the social, population and biomedical sciences. Due to the high levels of community trust established through the qualitative research on women’s perceptions, the team was able to achieve a high response rate in the survey and clinical components of the research.¹⁴ The study found that women had a high prevalence of reproductive morbidity, in particular reproductive tract infections and vaginal and uterine prolapse, and although the symptoms of these conditions were often debilitating, women considered them a normal part of a woman’s life, not requiring medical attention.^15–19

The Giza study contributed immediately to global discussions about how, practically, to implement the reproductive health agenda as discussed at the ICPD and specifically the need to broaden health services to meet the full range of women’s health needs. It also changed the way physicians conceived of women’s health, and influenced local programmes. The RHWG collaborated with the Egyptian Ministry of Health in three rural health centres to improve the provision of health care by incorporating the key concerns that were at the heart of the reproductive health approach.¹³

The innovations of the Giza study were several: a truly interdisciplinary approach; pointing to the need to understand both women’s perspectives and clinical conditions to assess reproductive morbidity accurately; a women-centred and community-based focus producing important new insights into the reasons behind the underutilisation of services; and a collaborative intervention with the public sector health system to improve quality and increase utilisation of services. The Giza study led directly to related work by RHWG members in Egypt, Jordan²⁰ and Lebanon²¹ on the prevalence of reproductive morbidity conditions. It also inspired work on problems of quality of care of reproductive health services²² and on the role of the education system in influencing skills and attitudes of Ob-Gyn specialists, as well as on the importance of dignity in doctor–patient relationships. The Giza study also inspired important work by anthropological colleagues within the RHWG network on women’s perceptions of their health in the region²³ and inspired an interdisciplinary group in Palestine to launch a study in Nablus on women’s perceptions of health.²⁴

The Giza study inspired further multidisciplinary research projects on other topics in women’s health in the region, and provided a model of a balanced and respectful collaboration among disciplines that are too often seen hierarchically in the region.

Maternal health: women’s experience at the core of childbirth research

A second example of how local research by network member intertwined innovatively with global concerns comes from studies on maternal health, specifically the process of delivery. In large part, this regional research was stimulated by the work of Oona Campbell and colleagues at the London School of Hygiene and Tropical Medicine working on maternal health internationally, who had pointed to the increasing emphasis globally on encouraging women to deliver in health-care facilities, even though the quality of those services may not be optimal. Researchers in Egypt, Lebanon and Syria had been having similar concerns about the quality of medical care provided locally during delivery, and the lack of women’s choices over hospital practices during childbirth, given the increasing medicalisation of the birth process and minimal pressure to involve women in choices around childbirth. Most of the research in the region to date, however, had been on home births and traditional birth attendants, and largely ethnographic in character, leaving practices of and experiences of “normal” (i.e. uncomplicated vaginal) delivery at health facilities an important and neglected area of research.²⁵ One early study, for example, that anticipated later developments was conducted in 1997 in 39 national hospitals in Lebanon, with the intention of providing baseline information provided by heads of maternity wards on practices of normal delivery, and the extent to which women were able to exercise choice in the process.²⁶ This study was later replicated by network members in Jordan²⁷ and inspired other work in Saudi Arabia.²⁸

Subsequently, a number of researchers who were members of the RHWG formed a group to conduct research in Lebanon, Syria,²⁹ Egypt,³⁰ the occupied Palestinian territory³¹ to examine hospital practices of labour and delivery, evaluate findings against evidence-based obstetrics, and importantly to try to understand the experience of “normal” childbirth, not only through the eyes of the practitioners, but particularly from the women’s point of view. This research – some of it comparative – was very much in contrast to the prevailing concern of practitioners and policy circles with the needs of “high risk” (i.e. with a high risk of a medical complication) pregnancies.²⁵

A variety of research techniques were used in these studies to capture the experience of birth in the institutional setting, such as questionnaires, some with scales to record frequency of practices, direct observation in delivery room and wards, and qualitative narratives of events. Through these activities, in 2001, the multidisciplinary groups of researchers from Egypt, Lebanon, the occupied Palestinian territories and Syria decided to form a network building on their earlier research and with separate funding entitled the Choices and Challenges in Changing Childbirth (CCCC). Over time, it expanded beyond delivery to examine standard approaches to prenatal, intrapartum and post-partum care.³²

Collectively, these studies attempted to problematise the institutionally based process of what are medically termed “normal” births at a time when research and policy tended to highlight the two ends of the birthing process, home births or high-risk cases and obstetric emergencies. In the early 2000s for example, a multidisciplinary team consisting of obstetricians, a public health physician, an anthropologist, a neonatologist, and a statistician, designed and conducted the first study of hospital-based “normal” labour and delivery practices in Egypt at the largest obstetric teaching hospital in Cairo, El Galaa. The study involved categorising over forty practices of normal labour by a trained observation team, using a special checklist developed for the study, and comparing this finely grained documentation against the expectations developed by the World Health Organization concerning normal birth.³⁰ The thrust of the observational element as a methodological innovation was really substantive: to document birth as a process rather than focusing on the clinical outcomes.³³ Clearly, many practices, such as inappropriate labour induction, posed health risks to women, and some were amenable to modification when results were discussed with the hospital managers. Ultimately, many practices were found to be related to health system constraints, such as overcrowding and underfunding, rather than simple negligence, but even then, sharing of the information enabled hospital managers to improve the care given.^30,33,34

From the beginning researchers in this group were committed to eliciting and understanding women’s experiences of delivery and maternity care, which had been given little emphasis until then. Thus, an early study in Lebanon by interviewing women in their home (rather than in hospital where they could be reluctant to be critical) revealed that many aspects of childbirth experiences were uncomfortable to women.³⁵ Syrian researchers went further by testing interventions that could improve women’s experiences, whether through post-natal home visits³⁶ or by improving providers’ communication skills.³⁷

The CCCC research network, thus, emerged with an integral link to the RHWG, membership overlaps between the two, and its findings have been consistently presented at the wider RHWG network. More recently, members have undertaken implementation research, which has been presented at RHWG meetings and benefited from an interdisciplinary discussion there. For example, one study explored the local effectiveness in three Arab countries of the globally recommended practice of clinical audits for improving management of “near miss” cases (women who nearly died in pregnancy and childbirth).³⁸ Another implementation research project explored whether allowing a labour companion (in hospitals where it was either not allowed or not encouraged) in Egypt, Lebanon and Syria would be effective and acceptable in the context of public hospitals in the region.³⁹

An emerging topic among RHWG members beyond the childbirth group is the investigation of the rise in already high rates of caesarean sections in the region.^40,41 While a global worry, it has its own regional and country-specific dynamics. One recent study by RHWG members on population discourses in Turkey found that some doctors and nurses viewed the measures to reduce C-sections as part of the government’s pronatalist policy drive, together with making family planning, including abortion, services difficult to access. Since more than two C-sections were not medically recommended, tighter control over this surgical procedure, it was argued, would serve well the revival of pronatalism.⁴¹

In conclusion, the broad set of research initiatives related to maternal health – grounded in the cultural and health system context of region – contributed to the ongoing international debates about the quality of maternal health care and the importance of women’s experiences in assessing quality.⁴²

Wars, conflicts and social suffering

As part of the lived reality of everyday life in the occupied Palestinian territories, a focus on the relationship between war/conflict and health has been, unavoidably, a part of the research interest of Palestinian scholars in the network from early on. It was partly these studies that generated and maintained the impetus to go beyond a focus on women to a critical examination of the social and political determinants of health for all. They asked how reproductive health, or indeed health more generally, could ever be understood separately from the violence and stresses of Israeli military occupation. Underscoring the importance of connecting physical wellness with psychosocial considerations, they introduced the notion of social suffering, which affects entire communities, not just individuals, into their conceptual framework. They developed measures based on local experience, including humiliation, distress, human insecurity and deprivation, emphasising the effects of exposure to political violence on well-being and health outcomes.^43–49

Studies by Palestinian researchers, who are also members of the childbirth research group described above, brought in a different dimension to discussions of the implications of conflict with their focus on maternal care and delivery. This accumulation of knowledge – on maternity care, particularly delivery, under conditions of conflict and siege – is very relevant given the current context of increasing violence in the region. These studies document women’s experiences with childbirth in conflict settings, and provide valuable clues about specific problems, such as giving birth under Israeli military occupation, where Israeli army checkpoints regularly slow and often prevent the movement of women in labour to medical facilities.⁵⁰ A study conducted by telephone interview – given difficulties of West Bank researchers accessing Gaza – also explored the experiences of women who gave birth and the attending midwives during the 22-day Israeli attack on Gaza December 2008 to January 2009.⁵¹ The study shows vividly “the vulnerability and trauma women experience when there is no safe place for childbirth”, and how the midwives were “unprepared both materially and psychologically to attend births outside a hospital setting”.⁵¹

Research under this theme included analyses of the impact of violence in different settings, in terms of a variety of forms of pain, suffering, ways of survival, coping, as well as on the efforts of humanitarian organisations to aid and protect populations. Given the expanding waves of military conflict, occupation and proxy fighting now engulfing large areas of the region, the group is now involved extensively in research on refugee experience, emergency and regular care in conflict times, and on the goals and implementations of humanitarian assistance.^52–54 This work on conflict has now reverberated within the RHWG and led other scholars in the Arab world, who were not part of the RHWG, to put conflict, violence and war as a fundamental frame for examining the causes of human suffering, morbidity, disability and mortality.

All three themes of research described above benefited from the modus operandi of the RHWG, in providing mentorship, critical but supportive feedback and above all, contextualised understanding. Rather than defining a research agenda per se, the network provided a forum to disseminate research and identify emerging research in the region, and in so doing inspired further research on similar themes. This way of operating is described further below in the context of presenting the organisational characteristics and the historical trajectory of the group, from the perspective of its goal of advancing research capacity in the region.

Strengthening research capability

The RHWG began its life in the 1980s under the influence of the Middle East Awards (MEAwards), a successful competitive grants programme, at the time created by the Cairo office of the Population Council, for the purpose of fostering research capability in the region. MEAwards provided funding and mentorship for researchers based in the Arab world and Turkey, and over time created a community of scholars from several disciplinary perspectives: economics, sociology, demography, anthropology, history, urban planning and public health. MEAwards built capacity for research through a research awards programme implemented by an advisory committee of active productive researchers from the region, and by organising small, intensive meetings of senior and junior scholars from several disciplines to discuss emerging and priority questions of theoretical importance and to encourage methodological rigour and invention.⁵⁵ It is worth noting that a regional grouping that connected researchers from the Arab countries and Turkey was unusual at the time, and time has shown that the similarities and differences in these contexts have proved exceptionally productive to their research.

The historical evolution of the RHWG partly explains its geographic composition. Several of its founding members were active participants in MEAwards. This awards programme had laid the basis for linkages among scholars across the region, representing a critical accumulation of regional bonds, in contrast to a prevalent pattern in the region where most scholars of note in the field had their training and research interests oriented towards Europe and the North Atlantic. They recognised that challenging received wisdom and creating new frameworks for analysing reproductive health required, like MEAwards, a new community of researchers, but one that brought together the social and health sciences. And like MEAwards, that community would be most productive if it not only crossed disciplines and generations, but also included Arab countries and Turkey. They also understood the importance of mentorship of less experienced researchers throughout the stages of research. Because the group had emerged in connection with this earlier awards programme, it was influenced by the latter’s definition of regional scope, as Middle East and North Africa, including Turkey. Over time, the impetus provided by historical continuity evolved within the RHWG as it became an attractive forum for both Arab and Turkish scholars who were interested in sharing perspectives of development in this wider region by listening to local voices and discovering mutualities as well as unexpected divergences in the ways in which health, particularly reproductive health, is produced locally. Such South-South linkages, which have taken many shapes in diverse platforms, provide epistemological and institutional ways of resisting North–South imbalances in the development of knowledge.

Due to the involvement of both Arab and Turkish researchers, English became the main language of MEAwards and the RHWG for the same reason. At the same time, however, the deliberate choice of English as a language that was comprehensible to both Arab and Turkish researchers meant that it was sometimes difficult to identify francophone North African researchers whose command of English was sufficient for meaningful intellectual exchange.

The RHWG has enthusiastically welcomed the participation of PhD students and newly graduated scholars, recognising the challenges faced by younger researchers in the region. For those who complete doctoral degrees in Europe or North America, the transition back to work in regional institutions is often difficult. Some find themselves isolated for political or social reasons or discover that they lack close colleagues sharing similar interests. They risk being captured by the financial incentives and prestige of serving as the local implementer of global projects or conducting local needs assessments for international aid agencies with little scope for conceptual or innovative research. The competing responsibilities of work and family add stress. And for others, the challenges are even more stark: how do they continue with research when lives and livelihoods are in jeopardy or lost to conflict and instability?

Reflecting on the ways in which participating in the network has altered the lives of its participants as researchers, one can detect several paths. The earliest RHWG members learned from each other in that several were participants in the interdisciplinary Giza Reproductive Morbidity Study. The individuals involved in the study respected each other on a personal level and were open to learning the language of other disciplines and to developing a basic appreciation of what those disciplines could offer the group endeavour. They gradually gained the capacity for interdisciplinary research by doing it, and by persevering through a sometimes trying process. The more explicitly political social sciences created unease among the health scientists, who had always assumed the possibility of scientific neutrality. Including gender and other power differentials in the analytical frame was a new and unsettling experience, but sustained interaction in a multifaceted research effort over time lessens such tensions. At the same time, developing relevant frameworks and metrics challenged social scientists and some public health researchers to exert efforts to understand the biological basis of health conditions and their symptoms, as well as to appreciate the difficulties of meaningfully translating concepts into various numerical tools.

As the work developed and expanded, so did the group. Scholars interested in interdisciplinary, locally grounded health research from Morocco to Iraq, Yemen, Oman and from Sudan to Turkey were invited to annual meetings. Proposals for seed funding (small seed grants offered by the network) helped to initiate research. Small follow-up meetings provided opportunities for the design of comparative studies in different countries and enabled the mentorship of younger researchers at different phases of research: asking the right question for the country and context, study design, field research and data gathering, analysis, write up and dissemination of findings. At every annual meeting, new researchers joined the network.

Most of all the RHWG has influenced the outlooks and careers of young researchers who want their work to be grounded locally and to think critically about the global debates, and for whom the RHWG has now become their vital research community. Through the RHWG they learn about regional realities beyond their own national experience, which enriches their teaching and research. Indeed mentorship from a community of critical but supportive more senior researchers has in many instances facilitated their return home, the attainment of recognition and promotions, and the advancement of their academic careers bringing innovative perspectives to local, regional and international fora.

An enduring network and its relevance: lessons from experience

No one who attended the first meetings of the RHWG at the Population Council in Cairo in the late 1980s would have imagined that the group would have had such a long life. Sustaining a community of knowledge like the RHWG is not easy in a volatile region like the Middle East, but some tentative explanations may be advanced.

First and foremost, the RHWG met a strongly felt need among researchers in the region to connect with other researchers, sharing an interest in health and well-being in the Arab countries and Turkey. The relevance of this grouping has grown stronger with recent developments and political conflicts in the region that increase the risk of isolation. It is compelling to learn about regional commonalities and differences from individuals embodying first-hand knowledge, and few fora exist to make this possible. It is often easier for researchers to link to mentors and colleagues in Europe or North America than from the region, and intellectual isolation is possible even in well-established academic departments.

The RHWG has always fostered a conversation with globally emerging themes, not just offered the opportunity to learn from the region. This global conversation materialised in two ways. From the beginning, members of the group, already from varied traditions of research and learning, were themselves part of different global networks. They brought those ideas and professional connections to the RHWG. In addition, well-chosen keynote speakers at each annual meeting reinforced the global intellectual connections, including with the Global South. In recent years, keynote speakers have addressed challenging themes, such as reproductive health in the context of the Global Sustainable Development Goals, Islam and family law in the Arab countries, and the challenges of social science research in the region.

A second and key factor in the longevity of the RHWG is the continuity of funding. The RHWG received crucial financial support from the Ford Foundation from 1988 until 2007, with eight consecutive grants over nearly 20 years. Initial funding covered the costs of coordination, programme support, annual meetings, thematic meetings, study groups and other activities such as regional exchanges and seed funding for new research projects. The coordinator acted as research leader, mobiliser and manager of the working group, many of whom were involved in the Giza Morbidity Study. Over time, the Ford Foundation grants were complemented by funds from other sources for research projects and meeting attendance. When the Ford Foundation funding ended, the group secured continuing funding from the Canadian International Development Research Council. Existing funds currently offer partial support to the coordinator and a programme manager, and expenses for members to meet and to sustain the network and some research costs.

Adequate core or operational funding, particularly for support for a coordinator and assistants, is crucial in the early years of a network while working methods are being developed and connections among researchers established. But the need for operational funding never goes away, and critical network activities, such as meetings and expanding the membership, are often undervalued by funders.⁵⁶ A recent WHO publication analysing factors leading to successful research networks underscored the challenge of finding donors willing to fund this network infrastructure.⁵⁷

Dependence on continuous external funding thus is a key point of vulnerability for research networks. At present, funding research networks is not fashionable among donors, who are under pressure for short term wins and quick demonstrable impact. Research networks take time to build and demonstrating impact is complex.

In recent years, much of the organisational and coordination work of the RHWG is done by members who are willing and able to volunteer their time, and who work in institutions that give them the needed flexibility. Planning the annual meeting alone requires many hours of work by the Coordinator and Consultative Committee. The Coordinator and Consultative Committee are currently among the RHWG’s most senior members, with several in or approaching retirement. Younger members of the RHWG may not be in a position to share the burden of group organisation and governance; they often face the constraints of long hours and non-supportive institutional work environments, making it difficult to give time to the RHWG, especially without financial compensation to their institution. Perhaps the RHWG example will encourage funders to return to supporting research capacity strengthening and research networks infrastructure. Until then the question remains: who will do this unpaid organisational work in future?

A third factor explaining the longevity of the RHWG is its leadership and, as a result, the strong and enduring group spirit. Leadership has both organisational and intellectual dimensions. Huda Zurayk served as RHWG founding coordinator and led the group for ten years (1988–1998). She was able to attract a dedicated group of scholars and practitioners who were convinced of the pressing need to critique globally defined reproductive health frameworks and develop theories and methods appropriate to the context of the Arab world and Turkey. That period shaped the group’s priorities, values and organisational culture. The clear vision developed by members of the group also shaped the group’s commitment to giving voice to a regional perspective through excellence in research; encouraged generous and constructive criticism; and stressed collegiality and solidarity, not competition, among members. The RHWG grew slowly at first to maintain this spirit, which stood in stark contrast to many of the institutions in which members worked, and attracted them all the more to it. For a time following 1998, a regional Consultative Committee composed of senior members led the group. This formalised participatory governance, but was not efficient without a designated coordinator. Jocelyn DeJong, a faculty member at the American University of Beirut, picked up the coordination reigns on a part-time basis in 2008, and along with the Consultative Committee, has led the group true to the original spirit.

A final factor influencing the longevity of the RHWG is its solid institutional bases. From 1988 until 2004, the RHWG was housed in the Population Council Regional Office for West Asia and North Africa in Cairo, Egypt. From 2004 to the present, the group was hosted at the Faculty of Health Sciences, American University of Beirut, in Beirut, Lebanon. Both institutions have encouraged the intellectual and financial autonomy of the RHWG. At the same time, as well-established international institutions, they facilitated logistical practicalities and protected the group from local political problems. Along the way, the group explored the possibility of institutionalising itself as a local, free-standing research entity in Lebanon, Egypt or another location in the region. In the end, this option was ruled out due to legal complexities and political vulnerabilities, which are not small issues in the Middle East. Over the years, the RHWG has had other institutional support, with continuing staff assistance from a single individual with institutional memory (Noha Gaballah in Egypt) and the detailed documentation of annual meetings by rapporteurs (a tradition initiated by Cynthia Myntti). Hence, there exists an invaluable record of the group’s evolution.

Final thought on ‘centre-periphery’ in research

The RHWG emerged out of a desire by social and health scientists in the Arab world and Turkey to create new knowledge about health in their region, knowledge that is grounded in regional realities and concerns but in conversation with global research trends. The ambition was to produce research described by multiple adjectives: critical, innovative, relevant, grounded, rigorous, rich, reliable, diverse, women-centred, collaborative and interdisciplinary. Over the nearly three decades, the RHWG has had some success in supporting research described as such, and continues to instil confidence and a sense of community among like-minded researchers in the region.

But to be critical and innovative is difficult in research peripheries, such as the Middle East. A proper regional emphasis requires the mastery of global and local knowledge as well as the capacity to make local observations speak to the global and not be presented simply as a deviation from the universal or an argument for specificity. These considerations are particularly important where health, gender and bodies intersect because it is precisely here where generalising, universalist tendencies are so strong and where nuanced studies of the mutually constitutive roles of the physical and social are needed.

Members of the RHWG share a commitment to rigorous, relevant research on women’s and reproductive health, and public health more generally. But participation in the network offers members more than just an intellectually stimulating platform for sharing and learning. The collegial, supportive environment created in the RHWG is also a main attraction to members. Solidarity rules, whether in sharing childcare during meetings or encouraging the research of courageous colleagues in Syria. As a long-time member from Palestine (Rita Giacaman) observed, “This support helps individuals to cope in times when the home front has become the battlefront”.¹³

Notes

* The Population Council, founded in 1952 and based in New York, conducts research to address critical health and development issues. The Population Council has had a regional office in Cairo since 1978. The American University of Beirut, founded in 1866 and chartered in New York state, is a teaching-centered research university with strong research traditions in the social sciences and public health.

† Hind Khattab, at the time Director of Research, Delta Consultants, Cairo; the late Nabil Younis, Professor of Obstetrics and Gynecology, Al-Azhar University, Cairo; Huda Zurayk, at the time Senior Associate, The Population Council Regional Office for West Asia and North Africa, Cairo.