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Home , Fasting during Ramadan, Fasting in Islam, Ramadan, Zakat

Abstract There are clear exemptions in from in during sickness, , and . Yet, some Muslim women still elect to fast while sick, pregnant, or breastfeeding because of a confl uence of social, religious, and cultural factors. Little is known about the physiological effects of on the mother or her unborn baby, and thus nurses and other healthcare providers are faced with the diffi cult task of providing appro- priate medical advice to Muslim women regarding the safety and impact of their fasting. This article describes what is known about this topic and suggests that healthcare professionals learn as much as possible about the multicultural best practices and research-driven information about fasting in order to help Muslim women make informed decisions. Keywords: Beliefs; Fasting; Islam; Women.

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Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Suha Al-Oballi Kridli, PhD, RN Health Beliefs and Practices of MuslimRamadan Women During asting the of Ramadan is one of the . The fi ve pillars are an- Fasting the month of Ramadan is one of the nouncement of faith, praying fi ve times a day, (giving five pillars of Islam: (1) announcement of the poor), fasting during the faith, (2) praying five times a day, (3) Zakat month of Ramadan, and (pilgrimage onceF in a lifetime). Ramadan is the ninth (giving to the poor), (4) fasting during the month of the Islamic and is an important month because it was the month of Ramadan, and (5) Hajj (pilgrimage month in which the Qur’an, the holy book of Islam, was revealed. During this month, once in a lifetime). abstain from and drinking from sunrise to sunset. Since Ramadan is based on a Lunar calendar, it begins 11 or 12 days earlier each and it lasts 29 to 30 days advising them about the safety of fasting during preg- (Robinson & Raisler, 2005). Ramadan can occur in any nancy and breastfeeding. Providing this advice and counsel of the four seasons; it is considered more diffi cult to fast requires that the nurse understand and respect beliefs and in the summer than the winter due to the heat and longer practices during this time to be able to provide appropri- day hours (Zaidi, 2003). ate and sensitive care. This article discusses health beliefs The purpose of fasting is for Muslims is to learn and practices of Muslim women during the fasting month self-restraint from indulgence in everyday pleasures, for of Ramadan as well as provides recommendations to self-discipline; to develop God-consciousness; to develop nurses and other healthcare providers. The information self-control; to purify the body; and to empathize with is derived from the author’s experience as a researcher, as the poor and hungry (Cross-Sudworth, 2007; Zaidi, a Muslim healthcare provider, and from the literature. 2003). As stated in the Qur’an “O you who have be- The purpose of the discussion is to synthesize a review of lieved, decreed upon you is fasting as it was decreed upon research in context of the reproductive health of Muslim those before you that you may become righteous” (The women and fasting; to explore promising new innovative Qur’an, 2007; S 2, V 183). approaches to serving this population; and to make the Islamic law is very clear about the exemption from fast- case that additional research is necessary to better inform ing for the sick, menstruating, traveling, elderly, the breast- both theory and practice. feeding and pregnant, and those unable to understand the purpose of fasting during Ramadan. Yet, some Muslim Sexual Relations and Menstruation women may still choose to fast while pregnant and breast- Islamic law is also very clear on the two areas of sexual feeding (Ertem, Kaynak, Kaynak, Ulukol, & Baskan relations and menstruation during the month of Rama- Gulnar, 2001; Josooph, Abu, & Yu, 2004; Pearce & dan. Fasting Muslim women must abstain from sexual Mayho, 2004; Robinson & Raisler, 2005; Zaidi, 2003). relationships from to dusk for all the days of the The holy month of Ramadan is an important time for month of Ramadan. As stated in the Qur’an “It has been Muslim women, but nurses and other healthcare provid- made permissible for you the night preceding fasting ers taking care of Muslim women face the diffi cult task of to go to your wives [for sexual relations]. They are

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Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. clothing for you and you are clothing for them” (The (2000), an increased risk of hyperemesis gravidarum in Qur’an, 2007; S 2, V 183). fasting women during the fi rst month of pregnancy was Muslim women are exempt from fasting during the found. In another study by Malhotra, Scott, Scott, Gee, period of menstruation and up to 40 days following and Wharton (1989), the maternal cortisol of fasting childbirth as it interferes with cleanliness and pu- women was elevated. Mirghani, Weerasinghe, Ezi- rity (Kridli, 2002). However, they are expected to make mokhani, and Smith (2003) found a reduction in fetal up the missed fasting days before the following Rama- breathing movements due to the low level of blood glucose dan. To avoid this, many Muslim women use oral contra- concentration in fasting pregnant mothers. In a more recent ceptives to postpone their menstrual cycle as they fi nd it study, Mirghani, Weerasinghe, Smith, and Ezimokhani more diffi cult to fast alone at a later time to make up the (2004) found a reduction in fetal biophysical profi le in missed days (Zaidi, 2003). fasting pregnant mothers, which could indicate a certain level of fetal compromise. Finally, Bandyopadhyay, Pregnancy Thakur, Ray, and Kumar (2005) stated that insuffi cient Many published and online sources confi rm that Muslim fl uid intake during pregnancy due to fasting increases women are exempt from fasting Ramadan during preg- Muslim women’s prevalence of urinary tract infections. nancy (Josooph et al., 2004; Malik, Mubarik, & Hussain, Other studies demonstrated that fasting has no effect 1996; Pearce & Mayho, 2004; Sulimani, 1991). This ex- on the unborn baby. For example, Cross, Eminson, and emption is likely based on the interpretation that fasting Wharton (1990) found that maternal fasting during during pregnancy causes hardship and diffi culties the Ramadan did not affect the birthweight of babies born at same way illness does. The Qur’an states “[fasting for] a full term. In another study by Kavehmanesh and Abol- limited number of days. So whoever among you is ill, or ghasemi (2004) maternal fasting, during Ramadan, did on a journey [during them]—then an equal number of not affect neonatal birthweight. Finally, Dikensoy et al. other days [are to be made up]. And upon those who are (2008) found that maternal fasting did not lead to keto- able [to fast but with hardship]—a ransom [as substitute] nemia or ketonuria in pregnant women. They also found of feeding a poor person [each day]” (The Qur’an, 2007; that it did not affect intrauterine fetal development or the S 2, V 183). fetus’s health. A clear exemption for pregnant women was found in Regardless of the effect of fasting on the health status the Sharif referred to by Abdullah Ibn Abbas “If of the mothers and their unborn babies, some pregnant a pregnant women fears for herself (i.e., for her health) or Muslim women may choose to fast. For example, in a the breastfeeding woman fears for her child in Ramadan, study by Josooph et al. (2004) most Muslim women they should break their fast and feed a poor person for chose to fast during pregnancy with support from their each day (they miss) and they do not have to make up the spouses and other family members. However, these women fast” (Hallaq, 2007, p. 550). Hadith Sharif is a report of lacked the basic religious knowledge regarding Islamic law saying based on the teachings and of fasting during pregnancy. In an- practices of the prophet Muham- other study by Robinson and Raisler mad. It is considered to be a main (2005), pregnant Muslim women source of after Qur’an. Many published and online avoided discussing fasting with Islam protects the child even their healthcare providers for fear before its birth which explains sources confirm that of being treated disrespectfully or why Muslim scholars exempt a Muslim women are exempt advised against fasting pregnant woman if she believes that fasting may cause harm to her from fasting Ramadan Breastfeeding health and/or to her unborn baby As in pregnancy, there is no clear (Josooph et al., 2004). Some schol- during pregnancy. mention of exemption in the Qur’an ars emphasize the need to make up for breastfeeding women from fast- the missed days once the pregnancy ing Ramadan. Based on the Qur’an, is over while others emphasize it is clear that Muslim women who giving money and food to the poor are breastfeeding during postpar- or needy or the ransom. tum are exempt from fasting due to A limited number of studies lack of purity, during this period, as have investigated the unclear effect in menstruation (Kridli, 2002). A of fasting on the health status of clear exemption for breastfeeding the mother and her unborn baby women was found in the Hadith during pregnancy. Some research sheriff referred to by Anas Ibn Malik fi ndings demonstrated negative Al-Kabi “Draw near and I shall tell effects of fasting on the mother you about and fasting. and her unborn baby. For example has remitted half of the prayer for in a study by Rabinerson, Dicker, the traveler and (he has remitted) Kaplan, Ben-Rafael, and Dekel fasting for the traveler, the women

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Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. who is suckling an infant and the women who is pregnant” advice regarding managing their illness while fasting (Hallaq, 2007, p. 552). for fear of being discouraged from fasting or getting a Many published and online sources exempt Muslim stricter diet and blood glucose monitoring. However, women from fasting while breastfeeding. They base their when not receiving medical advice, diabetic patients exemption on the fact that Islam values life and seeks to may take their medication irregularly or use inappropri- fulfi ll and satisfy the child’s vital needs; therefore, a woman ate diet, which may lead to serious side effects such as is permitted to break a fast to save a life. If fasting is hypoglycemia (Sulimani, 1991). going to harm the infant then the Muslim mother should Several recommendations have been made in the liter- break her fast to save the life of her infant who depends ature regarding management of for these women. on her breast for nourishment. For example, Sulimani (1991) believed that with proper Despite this clear exemption, some Muslim women instructions regarding diet management while fasting, it may elect to fast Ramadan while breastfeeding. For ex- is possible for diabetic patients to control this ample, in a study by Ertem et al. (2001) the attitudes and during Ramadan. He developed an algorithm for the practices of breastfeeding mothers regarding fasting dur- management of diabetic patients during Ramadan for ing Ramadan were investigated. They found that 22% of this purpose. For example, a medication that is normally breastfeeding mothers perceived a decrease in their breast given in the morning would be given at sunset meal and milk production, and 23% reported increasing the a medication that is normally given in the evening would amount of infant supplements during fasting. Most be given at the predawn meal during Ramadan. Recom- mothers (76%) believed that fasting decreased their mendations regarding dosage adjustments based on diabetic breast milk and 65% believed that breastfeeding mothers patient condition, during Ramadan, are also provided in should not fast. However, 41% of the mothers who be- this algorithm. Pinar (2002) also made clear recommenda- lieved that fasting decrease breast milk production and tions to healthcare providers that are aimed at improving 34% of those who believed that breastfeeding mothers the quality of care of diabetic Muslims. The recommen- should not fast, were fasting. Many Muslim women dations included dietary compliance, dosage adjustment choose to fast during Ramadan do it for spiritual reasons of medication, home blood glucose monitoring and exer- or because they fi nd it more diffi cult to fast alone at a cising cautiously during Ramadan. Medication noncom- later time if they have to make up the missed days (Cross- pliance has been related to fasting Ramadan (, Siddiqui, Sudworth, 2007). Anjum, Lohar, & Shaikh, 2007; Aslam & Assad, 1986; There is a lack of knowledge about the actual effects Malik et al., 1996); some Muslims believe that using oral of fasting while breastfeeding on the mother–infant rela- medications, injections, or inhalers during the fasting tionship and consequently the infant’s health. Research hours breaks their fast (Qaisi, 2001). Others believe that states that fasting causes physiological changes such as using only oral and intravenous medications would break “sleepiness, lack of concentration, weakness, exaggerated their fast (Ali et al., 2007). Nose drops, creams and oint- responsiveness, irritability, nervousness and aggressive- ments, suppositories, and patches are considered reli- ness” (Afi fi , 1997, p. 232). The effect of such changes on giously proper to use during the fasting hours (Ali et al., the breastfeeding mother and her production of breast 2007; Qaisi, 2001). As a result, depending on type of milk needs to be investigated. medication being used during Ramadan, patients may change the way they take their medication arbitrarily, Sickness and Medication which could lead to serious medication interaction and According to the Islamic Law, a sick person is exempt adverse outcomes (Ali et al., 2007; Aslam & Assad, from fasting from 1 day or for all of 30 days depending 1986; Qaisi, 2001). on her condition (Pinar, 2002). A sick person is expected to make up the missed fasting days. If a person is unable Clinical Implications to make up the missed days, she is expected to feed or Understand the Context by Finding out the Woman’s pay the poor or needy to make it up. The Qur’an states Beliefs About Fasting “.... and whoever is ill or on a journey—then an equal Imbedded in the clinical and medical implications of number of other days. Allah intends for you ease and fasting in pregnant women is a very complex social, reli- does not intend for you hardship and [wants] for you to gious, and spiritual context that infl uences the health complete the period and to glorify Allah for that [to] beliefs and practices of Muslim women, especially in which He has guided you; and perhaps you will be grate- Ramadan. These factors should all be considered along ful” (The Qur’an, 2007; S 2, V 183). Despite this clear with common sense and common knowledge when con- exemption, some Muslims who are ill and/or on a special sidering how to meet the health and medial needs of this diet choose to fast regardless of the medical advice and population (Josooph et al., 2004). For example, many their health status (Al-Qattan, 2000; Aslam & Assad, Muslim women feel obligated to fast while pregnant, 1986; Karaagaoglu & Yucecan, 2000). breastfeeding, or when they are ill due to social pressure Diabetes is the most commonly studied disease in from family and spiritual reasons. These infl uences may Ramadan due to the complicated management of this be diffi cult to understand for those who are outside of disease while fasting. According to Whitelaw (2005) and the cultural environment and societal context in which Pinar (2002) many diabetic Muslims do not seek medical the women live. Accordingly, nurses and other healthcare

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Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. providers are faced with a dif- fi cult task of providing medi- cal advice to Muslim women regarding health issues related to fasting during the month of Ramadan (Josooph et al., 2004). Josooph and coauthors recommended using a holistic approach when providing care to Muslim women while fast- ing, being sensitive to the reli- The purpose of fasting is for Muslims is to learn gious obligations that Muslim women feel. A Muslim woman self-restraint from indulgence in everyday pleasures, who does not believe that for self-discipline; to develop God-consciousness; fasting is going to reduce her breast milk production may to develop self-control; to purify the body; and to not accept any advice regard- ing breaking her fast. On the empathize with the poor and hungry. other hand, a Muslim woman who embraces this concept may be counseled about breaking her fast while breastfeeding. Counseling should include inson and Raisler (2005), American-born Muslim women information related to risks and benefi ts associated with were less likely to fast during Ramadan than immigrant fasting while breastfeeding. The same applies to pregnancy; Muslim women; (2) a distinction should be made be- therefore, nurses need to take the time to ask questions tween fi rst-time mothers and mothers with multiple chil- related to women’s beliefs regarding fasting during the dren. In a study by Josooph et al. (2004), multiparous month of Ramadan. Robinson and Raisler (2005) devel- women were found to be more likely to fast when com- oped specifi c guidelines for healthcare providers aimed pared to primigravidas. This could be related to the fact at improving the quality of care of fasting pregnant that fi rst-time mothers tend to be more worried about mothers. Their guidelines included the effect fasting may have on the health status of their 1. asking the pregnant Muslim patient about her plan for unborn baby. fasting; 2. assessing for risk factors that preclude fasting such as Are Medications Allowed During Fasting? diabetes, malnutrition, and renal calculi; It is also crucial to identify the beliefs of Muslim women 3. providing the patient with information about fasting during illness as many of them may choose to fast regard- safely; less of their health status. Nurses should be able to pro- 4. discussing warning signs with patients such as decreased vide positive support and advice about how to manage fetal movement and discomfort; their disease while fasting instead of advising them not to 5. increasing prenatal supervision; fast. Sharing the scientifi c evidence regarding the effect 6. advising the patient about not fasting if a medical of fasting on their illness is important so they can make reason exists. informed decisions. Muslims are more likely to pay atten- tion to the advice if they believed that their healthcare Review the Medical History for Conditions provider was knowledgeable about fasting (Robinson & That May Preclude Fasting Raisler, 2005). Understanding the woman’s medical history is essential, It is imperative that nurses and other healthcare for some health conditions (such as anemia) may compli- providers counsel their patients about potential hazards cate the decision to fast. If a Muslim woman chooses to related to medication noncompliance and importance of practice fasting, she should be counseled to seek medial following their prescribed regimen for their treatment care if she experiences signifi cant symptoms of head- (Aslam & Healy, 1986). They need to know which medi- aches, fainting, or other signs. There are other self-care cations are acceptable to their patients during Ramadan steps, such as staying indoors or ensuring proper , so they can better plan their care. Ramadan is the time which can help support a fasting person, while enabling for healthcare providers to make intelligent medical deci- them to remain true to their practice. sions by adjusting medications’ doses, strengths, and schedule (Qaisi, 2001). American-Born Muslim or Immigrant? Two distinctions should be made when providing care to Bending the Rules to Make Care More Accessible pregnant Muslim women during Ramadan: (1) a distinc- Attendance at healthcare clinics may decline during the tion should be made between immigrant Muslim women month of Ramadan due to changes in the women’s life- and American-born Muslim women. In a study by Rob- style during daylight hours. One possible solution to this

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Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. would be offering clinics that provide care to Muslim Aslam, M., & Assad, A. (1986). Drug regimens and fasting during Ramadan: A survey in . Public Health, 100(1), 49-53. women during the late day hours, after they break their Aslam, M., & Healy, M. A. (1986). Compliance and drug therapy in fast- fast and fi nish taking care of their families; this has ing Muslim patients. Journal of Clinical Hospital Pharmacology, proved to increase women’s attendance by Pearce and 11 (5), 1-5. Bandyopadhyay, S., Thakur, J. S., Ray, P., & Kumar, R. (2005). High Mayho (2004) who ran the fi rst Ramadan antenatal clinic prevalence of bacteriuria in pregnancy and its screening methods in in response to the low attendance of pregnant Muslim north . Journal of Indian Medical association, 103(5), 259-262. Cross, J. H., Eminson, J., & Wharton, B. A. (1990). Ramadan and birth women during Ramadan, and found success in maintain- weight at full term in Asian Muslim pregnant women in Birmingham. ing clinic visit rates. They stated that the Ramadan ante- Archives of Disease in Childhood, 65(10 Spec. No.), 1053-1056. natal clinic allowed pregnant women who believed that Cross-Sudworth, F. (2007). Effects of Ramadan fasting on pregnancy. British Journal of Midwifery, 15(2), 79-81. giving blood would break their fast to attend clinic after Dikensoy, E., Balat, O., Cebesoy, B., Ozkur, A., Cicek, H., & Can, G. breaking their fast. (2008). Effect of fasting during Ramadan on fetal development and maternal health. The Journal of Obstetrics and Gynecology Research, 34(4), 494-498. Gender Plays a Role Ertem, O., Kaynak, G., Kaynak, C, Ulukol, B., & Baskan Gulnar, S. (2001). The role of gender in Muslim society must be incorpo- Attitudes and practices of breastfeeding mothers regarding fasting rated into any treatment protocol or educational plan in Ramadan. Child: Care, Health and Development, 27(6), 545-554. Josooph, J., Abu, J., & Yu, S. L. (2004). A survey of fasting during preg- when counseling Muslim women about fasting. Nurses nancy. Singapore Medical Journal, 45(12), 583-586. and other healthcare workers must recognize the power- Hallaq, M. S. (Ed.). (2007). : According to Qur’an and (Vol. l). Darussalam, Riyadh. ful infl uence of men in the life of women—whether a Karaagaoglu, N., & Yucecan, S. (2000). Some behavioural changes father, brother, husband, or religious leader. Some of the observed among fasting subjects, their nutritional habits and pressure on women to fast can be linked to these pervasive energy expenditure in Ramadan. International Journal of Food Sciences and Nutrition, 51(2), 125-134. gender roles, but also to a lack of understanding by men Kavehmanesh, Z., & Abolghasemi, H. (2004). Maternal fasting and about what exactly are the tenets of Islam and Islamic neonatal health. Journal of Perinatology, 24(12), 748-750. law regarding fasting while breastfeeding and pregnant. Kridli, S. A. (2002). Health beliefs and practices among Arab women. MCN: American Journal of Maternal/Child Nursing, 27(3), 178-182. New approaches that seek to educate faith leaders and Malhotra, A, Scott, P. H., Scott, J., Gee, H., & Wharton, B. A. (1989). coordinate counseling efforts with these religious men in Metabolic changes in Asian Muslim pregnant mothers observing the Ramadan fast. British Journal of Nutrition, 61(3), 663-672. could augment and strengthen the education Malik, G. M., Mubarik, M., & Hussain, T. (1996). Ramadan fasting— activities of nurses. Effects on health and disease. Journal of the Association of Physi- Finally, the need for additional research and scholar- cians in India, 44(5), 332-334. Mirghani, H. M., Weerasinghe, D. S., Ezimokhai, M., & Smith, J. R. ship is urgent because of the lack of information in the (2003). The effect of maternal fasting on the fetal biophysical pro- area of health beliefs and practices of Muslim women fi le. International Journal of Gynecology and Obstetrics, 81(1), 17-21. during Ramadan. Qualitative research with different groups Mirghani, H. H., Weerasinghe, D. S., Smith, J. R., & Ezimokhai, M. (2004). The effect of intermittent maternal fasting on human fetal of women, breastfeeding or pregnant, would be highly breathing movements. Journal of Obstetrics and Gynecology, valuable and would provide new insights on addressing 24(6), 635-637. Pearce, A., & Mayho, P. (2004). Provision of antenatal care during these issues. Such research will give directions and guid- Ramadan. British Journal of Midwifery, 12(12), 750-752. ance for nurses and other healthcare providers as well as Pinar, R. (2002). Management of people with diabetes during Ramadan. researchers interested in the different aspects of fasting British Journal of Midwifery, 11(20), 1300-1303. Qaisi, V. G. (2001). Increasing awareness of health care concerns and women’s health. Original nursing research on the during Ramadan. Journal of American Pharmaceutical Association, impact of fasting and breastfeeding, coupled with new 41(4), 511. research fi ndings from qualitative studies will help to Rabinerson, D., Dicker, B., Kaplan, A., Ben-Rafael, Z., & Dekel, A. (2000). Hyperemesis gravidarum during pregnancy. Journal of Psychosomatic best practices into the future. ✜ Obstetrics and Gynecology, 21(4), 198-191. Robinson, T., & Raisler, J. (2005). “Each one is a doctor for herself”: Ramadan fasting among pregnant Muslim women in the United Suha Al-Oballi Kridli is an Associate Professor at Oak- States. Ethnicity and Disease, 11(Suppl. 1), S99-S103. land University, School of Nursing, Rochester, MI. She Sulimani, R. A. (1991). Ramadan fasting: Medical aspects in health and can be reachedvia e-mail at Email: [email protected]. in disease. Annals of Saudi Medicine, 11(6), 637-641. The Qur’an. (2007). (Shaheen International, Trans.) Riyadh, Saudi The author has disclosed that there are no fi nancial Arabia: AL-Muntada Al-Islami Trust. relationships related to this article. Whitelaw, S. (2005). Management of diabetes during Ramadan. Diabetic Medicine, 22(Suppl. 4), 21-23. DOI:10.1097/NMC.0b013e3182177177 Zaidi, F. (2003). : Implications for the midwifery practice. British Journal of Midwifery, 11(5), 289-292. References

Afi fi , Z. E. (1997). Daily practices, study performance and health during the ONLINE Ramadan fast. Journal of Royal Society and Health, 117(4), 231-235. http://navedz.wordpress.com/2010/08/10/ Al-Qattan, M. M. (2000). Burns in epileptics in . Burns, ramadan-a-few-words-on-merits-of-fasting/ 26(6), 561-563. Ali, R., Siddiqui, H., Anjum, Q., Lohar, M. I., & Shaikh, S. S. (2007). www.womensenews.org/story/071002/ Knowledge and perception of patients regarding medicine intake ramadan-feeds-mixed-views-maternal-fasts during Ramadan. Journal of the College of Physicians and Surgeons- , 17(2), 112-113.

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Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.