Each One Is a Doctor for Herself'': Ramadan Fasting Among Pregnant Muslim Women in the United States

D. `ÈACH ONE ISADOCTOR FOR HERSELF'': RAMADAN FASTING AMONG PREGNANT MUSLIM WOMEN IN THE UNITED STATES Trinka Robinson, MS, CNM; Jeanne Raisler, DrPH, CNM BACKGROUND AND Research about Ramadan fasting SIGNIFICANCE during pregnancy has not demonstrated any effect on Apgar scores, birth weight, Fasting during the Islamic month of gestational age at delivery, or infant Ramadan is a religious obligation for all well-being.19±21 Fasting for less than 15 healthy adult Muslims.1 This practice hours is not metabolically different from involves abstaining from all food and a physiological overnight fast for the liquids from dawn until sunset for 29 or healthy pregnant woman. Ketonemia 30 consecutive days. Since the Islamic and hypoglycemia frequently occur with calendar is shorter than the solar calen- more prolonged fasting; however, there dar, Ramadan slowly rotates through the is no evidence that this affects infant seasons. Thus, the total period of fasting outcomes.4,6 Non-stress tests are more can range from less than 12 hours to as likely to be non-reactive during the pe- much as 19 hours each day. riod of fasting, but return to reactivity Ramadan occurs during the majority after dinner.22,23 Stable gestational per- of pregnancies. Pregnant women may sons with diabetes who fast experience delay the fast if they fear for their health no increase in hypoglycemic symptoms or that of the baby. Like all Muslims and have improved glucose control.24 who cannot fast, they must make up the Although the research to date is gen- missed days by fasting at a later time, or erally reassuring, there is inadequate ev- in some cases, by feeding a poor person idence to conclude that prenatal fasting for each day that they did not fast.2,3 is safe. Many of the existing studies are No research was found in the United small or methodologically ¯awed. Some States about religious fasting during theoretical risks of Ramadan fasting pregnancy. Research in other countries, have not been studied, such as its effect however, found that most pregnant on amniotic ¯uid volume.25,26 The lit- Muslims do fast.4±7 This exploratory erature also raises yet unanswered ques- qualitative study examined the practice tions about its effect on the incidences of Ramadan fasting among pregnant of asymptomatic bacteriuria27 and hy- Muslim women in Michigan in order to peremesis gravidarum.28 provide insight into their beliefs, atti- tudes, decision-making, and experiences in the healthcare system. RESEARCH METHODOLOGY REVIEW OF THE A convenience sample of 32 Muslim LITERATURE women was recruited by lea¯et and word-of-mouth from several Muslim A large body of evidence demon- communities in southeast Michigan. strates the safety of Ramadan fasting for This area is home to a diverse popula- healthy non-pregnant adults. Some peo- tion of native and immigrant Muslims, ple with stable chronic medical condi- including many recent refugees and one tions can also fast safely.1,8±17 A British of the largest and oldest Arab commu- study found that non-pregnant Muslim nities outside of the Middle East.1,29 Par- From the Henry Ford Health Sciences patients rarely discussed fasting with ticipants had all been pregnant during Center, Detroit, Michigan. their healthcare providers.18 Ramadan, but were not prospectively Ethnicity & Disease, Volume 15, Winter 2005 S1-99 MENTAL HEALTH - Robinson and Raisler transcribed and analyzed using Atlas II Table 1. Demographic characteristics of the sample software.30,31 Fasted Last Pregnancy N N RESULTS Ethnicity African-American 6 4 ArabÐraised in United States 5 2* Incidence of Fasting ArabÐimmigrant 18 17 Overall, 28 of the 32 women chose European-American 1 1 Other immigrant 2 2 to fast for some time during at least one Age pregnancy. Thirty of the women had 21±25 2 2 been pregnant during Ramadan within 26±30 19 13² the previous two years. During that 31±35 4 3² pregnancy, ®ve of them did not fast at 36±40 7 6 all. Sixteen fasted throughout the entire 41±45 1 1 month. The remaining women fasted Para (total) 85 intermittently because of health con- 0 1 0 cerns. Immigrant women fasted more 1 4 2 2 9 9 days than those who were born in the 3 9 6² United States (mean525 vs 13 days, re- 4 9 8² spectively). Pregnant at time of interview 12 Participants reported that 60%± Education 90% of women in their communities in Less than high school 4 3 the United States fast during pregnancy. High school 6 5 They agreed that American-born wom- Some college 17 12* Postgraduate 5 5 en are less likely to fast than are immi- Annual income grant women, and estimated that the in- ,$20,000 16 15 cidence of fasting among American- $20,000±$40,000 5 4 born pregnant Muslims was 30%±50%. .$40,000 10 6* These estimates were consistent with the * Two did not have Ramadan during the pregnancy, but fasted in their other pregnancies. actual reported fasting behavior of the ² One did not have Ramadan during last pregnancy. focus group participants (Figure 1). Beliefs and Practices screened for whether or not they had tape-recorded focus groups lasting 1½ A recurring theme in every group fasted. Demographic characteristics of to 2 hours. All groups contained women was that, for many women, fasting was the sample are described in Table 1. who had and had not fasted during their simply the normal thing to doÐnot Each woman participated in one of six most recent pregnancy. The tapes were something that they actively decided. One participant explained: `Ì just assumed that I would fast and see how it goes. If, after a day or two, I found I could not do it, then I would stop.'' All but two women believed that fasting during pregnancy is safe for healthy women. They explained that total food intake is the same as when not fasting, and that the fetus ``takes its nourishment ®rst.'' Four women stated that fasting during pregnancy is not only safe, but also healthy. All participants agreed that a woman should not Fig 1. Reported fasting behavior for all pregnancies fast if it would hurt her or the baby, and S1-100 Ethnicity & Disease, Volume 15, Winter 2005 MENTAL HEALTH - Robinson and Raisler this was the only reason mentioned for ®cult this was for them. They animat- to fast. If he says `no,' we do not obey not fasting. They identi®ed warning edly discussed disadvantages, such as a him. It is a only matter of asking.'' signs, such as fatigue, excessive hunger decreased sense of connection with the Later one participant clari®ed that or thirst, nausea and vomiting, weak- community, loss of the feeling of Ram- Muslims are obligated to avoid harm. ness, and pre-existing or acute illnesses. adan, feeling guilty, and having to make All participants in every group agreed Another participant declared: up missed days. Many women described with her assertionÐ``We want to obey `Èach one is a doctor for herself. She her childhood memories of Ramadan in the scienti®c idea of the doctor. If we knows when she should fast and when vivid detail. One woman explained that don't do that, we will have a sin. But she should break her fasting.'' fasting was one of the ways that she we ask them to convince us scienti®cal- Eight participants said that women maintained her sense of cultural identity ly. We ask the doctors to give us proofÐ might not be aware if they were harm- and concluded, `Ì know I do things to show [us] pictures or videos, or make ing their baby. One woman recalled a with my kids now in Ramadan that my special programs to speak about these time when her husband had encouraged Mom used to do with me. And if you're things, and then we will obey them.'' her to stop fasting, and commented: not fasting, you kind of feel like you're ``Sometimes we have in our mind, falling out of that whole equilibrium of On Building Positive Patient- Òh, I can do this,' and we lose sight of memories.'' Provider Relationships all the things that are going wrong. Most women wanted help in assur- Family members sometimes, you know, Communication with ing a healthy pregnancy outcome. The have a different point of view.'' Healthcare Providers most common needs that they expressed All focus group participants had re- were to receive more information about In¯uences ceived, and strongly valued, prenatal fasting and to have their caregiver mon- Women fasted because they felt pas- care. Questions about communication itor the baby's well-being. They recom- sionately about the bene®ts of Rama- with their providers stimulated emo- mended providing handouts, verbal ad- dan. One woman described Ramadan as tional responses in every discussion. vice, and referrals to specialists, such as a time ``to charge my spiritual battery.'' Many women said they avoided talking a nutritionist or a knowledgeable Mus- ``Ramadan for me is a phase of time about prenatal fasting because they did lim nurse. Women who felt that their where I reduce my obligations outside not want to be treated disrespectfully or healthcare provider (HCP) was knowl- and focus inward. It's hard to ex- to be told to stop fasting. Others simply edgeable about Islamic fasting were plain to non-Muslims that fasting is a felt that they did not need advice. most likely to follow the advice. very kind thing for a Muslim body, spir- Nineteen women discussed fasting at The six women who mentioned that it, and soul.'' a prenatal visit during at least one preg- their HCP had given them advice about When women had health problems, nancy.

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