Beliefs, Fasting, Islam, Women.



  1. Kridli, Suha Al-Oballi PhD, RN


Abstract: There are clear exemptions in Islam from fasting in Ramadan during sickness, pregnancy, and breastfeeding. Yet, some Muslim women still elect to fast while sick, pregnant, or breastfeeding because of a confluence of social, religious, and cultural factors. Little is known about the physiological effects of fasting during Ramadan on the mother or her unborn baby, and thus nurses and other healthcare providers are faced with the difficult task of providing appropriate 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.


Article Content

Fasting the month of Ramadan is one of the five pillars of Islam. The five pillars are announcement of faith, praying five times a day, Zakat (giving the poor), fasting during the month of Ramadan, and Hajj (pilgrimage once in a lifetime). Ramadan is the ninth month of the Islamic Lunar calendar and is an important month because it was the month in which the Qur'an, the holy book of Islam, was revealed. During this month, Muslims abstain from eating and drinking from sunrise to sunset. Since Ramadan is based on a Lunar calendar, it begins 11 or 12 days earlier each year and it lasts 29 to 30 days (Robinson & Raisler, 2005). Ramadan can occur in any of the four seasons; it is considered more difficult to fast in the summer than the winter due to the heat and longer day hours (Zaidi, 2003).

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The purpose of fasting is for Muslims is to learn self-restraint from indulgence in everyday pleasures, for self-discipline; to develop God-consciousness; to develop self-control; to purify the body; and to empathize with the poor and hungry (Cross-Sudworth, 2007; Zaidi, 2003). As stated in the Qur'an "O you who have believed, decreed upon you is fasting as it was decreed upon those before you that you may become righteous" (The Qur'an, 2007; S 2, V 183).


Islamic law is very clear about the exemption from fasting for the sick, menstruating, traveling, elderly, the breastfeeding and pregnant, and those unable to understand the purpose of fasting during Ramadan. Yet, some Muslim women may still choose to fast while pregnant and breastfeeding (Ertem, Kaynak, Kaynak, Ulukol, & Baskan Gulnar, 2001; Josooph, Abu, & Yu, 2004; Pearce & Mayho, 2004; Robinson & Raisler, 2005; Zaidi, 2003).


The holy month of Ramadan is an important time for Muslim women, but nurses and other healthcare providers taking care of Muslim women face the difficult task of advising them about the safety of fasting during pregnancy and breastfeeding. Providing this advice and counsel requires that the nurse understand and respect beliefs and practices during this time to be able to provide appropriate and sensitive care. This article discusses health beliefs and practices of Muslim women during the fasting month of Ramadan as well as provides recommendations to nurses and other healthcare providers. The information is derived from the author's experience as a researcher, as a Muslim healthcare provider, and from the literature. The purpose of the discussion is to synthesize a review of research in context of the reproductive health of Muslim women and fasting; to explore promising new innovative approaches to serving this population; and to make the case that additional research is necessary to better inform both theory and practice.


Sexual Relations and Menstruation

Islamic law is also very clear on the two areas of sexual relations and menstruation during the month of Ramadan. Fasting Muslim women must abstain from sexual relationships from dawn to dusk for all the days of the month of Ramadan. As stated in the Qur'an "It has been made permissible for you the night preceding fasting to go to your wives [for sexual relations]. They are clothing for you and you are clothing for them" (The Qur'an, 2007; S 2, V 183).


Muslim women are exempt from fasting during the period of menstruation and up to 40 days following childbirth as it interferes with cleanliness and ritual purity (Kridli, 2002). However, they are expected to make up the missed fasting days before the following Ramadan. To avoid this, many Muslim women use oral contraceptives to postpone their menstrual cycle as they find it more difficult to fast alone at a later time to make up the missed days (Zaidi, 2003).



Many published and online sources confirm that Muslim women are exempt from fasting Ramadan during pregnancy (Josooph et al., 2004; Malik, Mubarik, & Hussain, 1996; Pearce & Mayho, 2004; Sulimani, 1991). This exemption is likely based on the interpretation that fasting during pregnancy causes hardship and difficulties the same way illness does. The Qur'an states "[fasting for] a limited number of days. So whoever among you is ill, or on a journey [during them]-then an equal number of other days [are to be made up]. And upon those who are able [to fast but with hardship]-a ransom [as substitute] of feeding a poor person [each day]" (The Qur'an, 2007; S 2, V 183).


A clear exemption for pregnant women was found in the Hadith Sharif referred to by Abdullah Ibn Abbas "If a pregnant women fears for herself (i.e., for her health) or the breastfeeding woman fears for her child in Ramadan, they should break their fast and feed a poor person for each day (they miss) and they do not have to make up the fast" (Hallaq, 2007, p. 550). Hadith Sharif is a report of saying based on the teachings and practices of the prophet Muhammad. It is considered to be a main source of religious law after Qur'an.


Islam protects the child even before its birth which explains why Muslim scholars exempt a pregnant woman if she believes that fasting may cause harm to her health and/or to her unborn baby (Josooph et al., 2004). Some scholars emphasize the need to make up the missed days once the pregnancy is over while others emphasize giving money and food to the poor or needy or the ransom.


A limited number of studies have investigated the unclear effect of fasting on the health status of the mother and her unborn baby during pregnancy. Some research findings demonstrated negative effects of fasting on the mother and her unborn baby. For example in a study by Rabinerson, Dicker, Kaplan, Ben-Rafael, and Dekel (2000), an increased risk of hyperemesis gravidarum in fasting women during the first month of pregnancy was found. In another study by Malhotra, Scott, Scott, Gee, and Wharton (1989), the maternal cortisol of fasting women was elevated. Mirghani, Weerasinghe, Ezimokhani, and Smith (2003) found a reduction in fetal breathing movements due to the low level of blood glucose concentration in fasting pregnant mothers. In a more recent study, Mirghani, Weerasinghe, Smith, and Ezimokhani (2004) found a reduction in fetal biophysical profile in fasting pregnant mothers, which could indicate a certain level of fetal compromise. Finally, Bandyopadhyay, Thakur, Ray, and Kumar (2005) stated that insufficient fluid intake during pregnancy due to fasting increases Muslim women's prevalence of urinary tract infections.


Other studies demonstrated that fasting has no effect on the unborn baby. For example, Cross, Eminson, and Wharton (1990) found that maternal fasting during Ramadan did not affect the birthweight of babies born at full term. In another study by Kavehmanesh and Abolghasemi (2004) maternal fasting, during Ramadan, did not affect neonatal birthweight. Finally, Dikensoy et al. (2008) found that maternal fasting did not lead to ketonemia or ketonuria in pregnant women. They also found that it did not affect intrauterine fetal development or the fetus's health.


Regardless of the effect of fasting on the health status of the mothers and their unborn babies, some pregnant Muslim women may choose to fast. For example, in a study by Josooph et al. (2004) most Muslim women chose to fast during pregnancy with support from their spouses and other family members. However, these women lacked the basic religious knowledge regarding Islamic law of fasting during pregnancy. In another study by Robinson and Raisler (2005), pregnant Muslim women avoided discussing fasting with their healthcare providers for fear of being treated disrespectfully or advised against fasting



As in pregnancy, there is no clear mention of exemption in the Qur'an for breastfeeding women from fasting Ramadan. Based on the Qur'an, it is clear that Muslim women who are breastfeeding during postpartum are exempt from fasting due to lack of purity, during this period, as in menstruation (Kridli, 2002). A clear exemption for breastfeeding women was found in the Hadith sheriff referred to by Anas Ibn Malik Al-Kabi "Draw near and I shall tell you about prayer and fasting. Allah has remitted half of the prayer for the traveler and (he has remitted) fasting for the traveler, the women who is suckling an infant and the women who is pregnant" (Hallaq, 2007, p. 552).


Many published and online sources exempt Muslim women from fasting while breastfeeding. They base their exemption on the fact that Islam values life and seeks to fulfill and satisfy the child's vital needs; therefore, a woman is permitted to break a fast to save a life. If fasting is going to harm the infant then the Muslim mother should break her fast to save the life of her infant who depends on her breast milk for nourishment.


Despite this clear exemption, some Muslim women may elect to fast Ramadan while breastfeeding. For example, in a study by Ertem et al. (2001) the attitudes and practices of breastfeeding mothers regarding fasting during Ramadan were investigated. They found that 22% of breastfeeding mothers perceived a decrease in their breast milk production, and 23% reported increasing the amount of infant supplements during fasting. Most mothers (76%) believed that fasting decreased their breast milk and 65% believed that breastfeeding mothers should not fast. However, 41% of the mothers who believed that fasting decrease breast milk production and 34% of those who believed that breastfeeding mothers should not fast, were fasting. Many Muslim women choose to fast during Ramadan do it for spiritual reasons or because they find it more difficult to fast alone at a later time if they have to make up the missed days (Cross-Sudworth, 2007).


There is a lack of knowledge about the actual effects of fasting while breastfeeding on the mother-infant relationship and consequently the infant's health. Research states that fasting causes physiological changes such as "sleepiness, lack of concentration, weakness, exaggerated responsiveness, irritability, nervousness and aggressiveness" (Afifi, 1997, p. 232). The effect of such changes on the breastfeeding mother and her production of breast milk needs to be investigated.


Sickness and Medication

According to the Islamic Law, a sick person is exempt from fasting from 1 day or for all of 30 days depending on her condition (Pinar, 2002). A sick person is expected to make up the missed fasting days. If a person is unable to make up the missed days, she is expected to feed or pay the poor or needy to make it up. The Qur'an states ".... and whoever is ill or on a journey-then an equal number of other days. Allah intends for you ease and does not intend for you hardship and [wants] for you to complete the period and to glorify Allah for that [to] which He has guided you; and perhaps you will be grateful" (The Qur'an, 2007; S 2, V 183). Despite this clear exemption, some Muslims who are ill and/or on a special diet choose to fast regardless of the medical advice and their health status (Al-Qattan, 2000; Aslam & Assad, 1986; Karaagaoglu & Yucecan, 2000).


Diabetes is the most commonly studied disease in Ramadan due to the complicated management of this disease while fasting. According to Whitelaw (2005) and Pinar (2002) many diabetic Muslims do not seek medical advice regarding managing their illness while fasting for fear of being discouraged from fasting or getting a stricter diet and blood glucose monitoring. However, when not receiving medical advice, diabetic patients may take their medication irregularly or use inappropriate diet, which may lead to serious side effects such as hypoglycemia (Sulimani, 1991).


Several recommendations have been made in the literature regarding management of diabetes for these women. For example, Sulimani (1991) believed that with proper instructions regarding diet management while fasting, it is possible for diabetic patients to control this disease during Ramadan. He developed an algorithm for the management of diabetic patients during Ramadan for this purpose. For example, a medication that is normally given in the morning would be given at sunset meal and a medication that is normally given in the evening would be given at the predawn meal during Ramadan. Recommendations regarding dosage adjustments based on diabetic patient condition, during Ramadan, are also provided in this algorithm. Pinar (2002) also made clear recommendations to healthcare providers that are aimed at improving the quality of care of diabetic Muslims. The recommendations included dietary compliance, dosage adjustment of medication, home blood glucose monitoring and exercising cautiously during Ramadan. Medication noncompliance has been related to fasting Ramadan (Ali, Siddiqui, Anjum, Lohar, & Shaikh, 2007; Aslam & Assad, 1986; Malik et al., 1996); some Muslims believe that using oral medications, injections, or inhalers during the fasting hours breaks their fast (Qaisi, 2001). Others believe that using only oral and intravenous medications would break their fast (Ali et al., 2007). Nose drops, creams and ointments, suppositories, and patches are considered religiously proper to use during the fasting hours (Ali et al., 2007; Qaisi, 2001). As a result, depending on type of medication being used during Ramadan, patients may change the way they take their medication arbitrarily, which could lead to serious medication interaction and adverse outcomes (Ali et al., 2007; Aslam & Assad, 1986; Qaisi, 2001).


Clinical Implications

Understand the Context by Finding out the Woman's Beliefs About Fasting

Imbedded in the clinical and medical implications of fasting in pregnant women is a very complex social, religious, and spiritual context that influences the health beliefs and practices of Muslim women, especially in Ramadan. These factors should all be considered along with common sense and common knowledge when considering how to meet the health and medial needs of this population (Josooph et al., 2004). For example, many Muslim women feel obligated to fast while pregnant, breastfeeding, or when they are ill due to social pressure from family and spiritual reasons. These influences may be difficult to understand for those who are outside of the cultural environment and societal context in which the women live. Accordingly, nurses and other healthcare providers are faced with a difficult task of providing medical 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 fasting, being sensitive to the religious obligations that Muslim women feel. A Muslim woman who does not believe that fasting is going to reduce her breast milk production may not accept any advice regarding breaking her fast. On the other hand, a Muslim woman who embraces this concept may be counseled about breaking her fast while breastfeeding. Counseling should include information related to risks and benefits associated with fasting while breastfeeding. The same applies to pregnancy; therefore, nurses need to take the time to ask questions related to women's beliefs regarding fasting during the month of Ramadan. Robinson and Raisler (2005) developed specific guidelines for healthcare providers aimed at improving the quality of care of fasting pregnant mothers. Their guidelines included


1. asking the pregnant Muslim patient about her plan for fasting;


2. assessing for risk factors that preclude fasting such as diabetes, malnutrition, and renal calculi;


3. providing the patient with information about fasting safely;


4. discussing warning signs with patients such as decreased fetal movement and discomfort;


5. increasing prenatal supervision;


6. advising the patient about not fasting if a medical reason exists.



Review the Medical History for Conditions That May Preclude Fasting

Understanding the woman's medical history is essential, for some health conditions (such as anemia) may complicate the decision to fast. If a Muslim woman chooses to practice fasting, she should be counseled to seek medial care if she experiences significant symptoms of headaches, fainting, or other signs. There are other self-care steps, such as staying indoors or ensuring proper sleep, which can help support a fasting person, while enabling them to remain true to their practice.


American-Born Muslim or Immigrant?

Two distinctions should be made when providing care to pregnant Muslim women during Ramadan: (1) a distinction should be made between immigrant Muslim women and American-born Muslim women. In a study by Robinson and Raisler (2005), American-born Muslim women were less likely to fast during Ramadan than immigrant Muslim women; (2) a distinction should be made between first-time mothers and mothers with multiple children. In a study by Josooph et al. (2004), multiparous women were found to be more likely to fast when compared to primigravidas. This could be related to the fact that first-time mothers tend to be more worried about the effect fasting may have on the health status of their unborn baby.


Are Medications Allowed During Fasting?

It is also crucial to identify the beliefs of Muslim women during illness as many of them may choose to fast regardless of their health status. Nurses should be able to provide positive support and advice about how to manage their disease while fasting instead of advising them not to fast. Sharing the scientific evidence regarding the effect of fasting on their illness is important so they can make informed decisions. Muslims are more likely to pay attention to the advice if they believed that their healthcare provider was knowledgeable about fasting (Robinson & Raisler, 2005).


It is imperative that nurses and other healthcare providers counsel their patients about potential hazards related to medication noncompliance and importance of following their prescribed regimen for their treatment (Aslam & Healy, 1986). They need to know which medications are acceptable to their patients during Ramadan so they can better plan their care. Ramadan is the time for healthcare providers to make intelligent medical decisions by adjusting medications' doses, strengths, and schedule (Qaisi, 2001).


Bending the Rules to Make Care More Accessible

Attendance at healthcare clinics may decline during the month of Ramadan due to changes in the women's lifestyle during daylight hours. One possible solution to this would be offering clinics that provide care to Muslim women during the late day hours, after they break their fast and finish taking care of their families; this has proved to increase women's attendance by Pearce and Mayho (2004) who ran the first Ramadan antenatal clinic in response to the low attendance of pregnant Muslim women during Ramadan, and found success in maintaining clinic visit rates. They stated that the Ramadan antenatal clinic allowed pregnant women who believed that giving blood would break their fast to attend clinic after breaking their fast.


Gender Plays a Role

The role of gender in Muslim society must be incorporated into any treatment protocol or educational plan when counseling Muslim women about fasting. Nurses and other healthcare workers must recognize the powerful influence of men in the life of women-whether a father, brother, husband, or religious leader. Some of the pressure on women to fast can be linked to these pervasive gender roles, but also to a lack of understanding by men about what exactly are the tenets of Islam and Islamic law regarding fasting while breastfeeding and pregnant. New approaches that seek to educate faith leaders and coordinate counseling efforts with these religious men in Mosques could augment and strengthen the education activities of nurses.


Finally, the need for additional research and scholarship is urgent because of the lack of information in the area of health beliefs and practices of Muslim women during Ramadan. Qualitative research with different groups of women, breastfeeding or pregnant, would be highly valuable and would provide new insights on addressing these issues. Such research will give directions and guidance for nurses and other healthcare providers as well as researchers interested in the different aspects of fasting and women's health. Original nursing research on the impact of fasting and breastfeeding, coupled with new research findings from qualitative studies will help to drive best practices into the future.



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Afifi, Z. E. (1997). Daily practices, study performance and health during the Ramadan fast. Journal of Royal Society and Health, 117(4), 231-235. [Context Link]


Al-Qattan, M. M. (2000). Burns in epileptics in Saudi Arabia. Burns, 26(6), 561-563. [Context Link]


Ali, R., Siddiqui, H., Anjum, Q., Lohar, M. I., & Shaikh, S. S. (2007). Knowledge and perception of patients regarding medicine intake during Ramadan. Journal of the College of Physicians and Surgeons-Pakistan, 17(2), 112-113. [Context Link]


Aslam, M., & Assad, A. (1986). Drug regimens and fasting during Ramadan: A survey in Kuwait. Public Health, 100(1), 49-53. [Context Link]


Aslam, M., & Healy, M. A. (1986). Compliance and drug therapy in fasting Muslim patients. Journal of Clinical Hospital Pharmacology, 11(5), 1-5. [Context Link]


Bandyopadhyay, S., Thakur, J. S., Ray, P., & Kumar, R. (2005). High prevalence of bacteriuria in pregnancy and its screening methods in north India. Journal of Indian Medical association, 103(5), 259-262. [Context Link]


Cross, J. H., Eminson, J., & Wharton, B. A. (1990). Ramadan and birth weight at full term in Asian Muslim pregnant women in Birmingham. Archives of Disease in Childhood, 65(10 Spec. No.), 1053-1056. [Context Link]


Cross-Sudworth, F. (2007). Effects of Ramadan fasting on pregnancy. British Journal of Midwifery, 15(2), 79-81. [Context Link]


Dikensoy, E., Balat, O., Cebesoy, B., Ozkur, A., Cicek, H., & Can, G. (2008). Effect of fasting during Ramadan on fetal development and maternal health. The Journal of Obstetrics and Gynecology Research, 34(4), 494-498. [Context Link]


Ertem, O., Kaynak, G., Kaynak, C, Ulukol, B., & Baskan Gulnar, S. (2001). Attitudes and practices of breastfeeding mothers regarding fasting in Ramadan. Child: Care, Health and Development, 27(6), 545-554. [Context Link]


Josooph, J., Abu, J., & Yu, S. L. (2004). A survey of fasting during pregnancy. Singapore Medical Journal, 45(12), 583-586. [Context Link]


Hallaq, M. S. (Ed.). (2007). Fiqh: According to Qur'an and Sunnah (Vol. l). Darussalam, Riyadh. [Context Link]


Karaagaoglu, N., & Yucecan, S. (2000). Some behavioural changes observed among fasting subjects, their nutritional habits and energy expenditure in Ramadan. International Journal of Food Sciences and Nutrition, 51(2), 125-134. [Context Link]


Kavehmanesh, Z., & Abolghasemi, H. (2004). Maternal fasting and neonatal health. Journal of Perinatology, 24(12), 748-750. [Context Link]


Kridli, S. A. (2002). Health beliefs and practices among Arab women. MCN: American Journal of Maternal/Child Nursing, 27(3), 178-182. [Context Link]


Malhotra, A, Scott, P. H., Scott, J., Gee, H., & Wharton, B. A. (1989). Metabolic changes in Asian Muslim pregnant mothers observing the Ramadan fast. British Journal of Nutrition, 61(3), 663-672. [Context Link]


Malik, G. M., Mubarik, M., & Hussain, T. (1996). Ramadan fasting-Effects on health and disease. Journal of the Association of Physicians in India, 44(5), 332-334. [Context Link]


Mirghani, H. M., Weerasinghe, D. S., Ezimokhai, M., & Smith, J. R. (2003). The effect of maternal fasting on the fetal biophysical profile. International Journal of Gynecology and Obstetrics, 81(1), 17-21. [Context Link]


Mirghani, H. H., Weerasinghe, D. S., Smith, J. R., & Ezimokhai, M. (2004). The effect of intermittent maternal fasting on human fetal breathing movements. Journal of Obstetrics and Gynecology, 24(6), 635-637. [Context Link]


Pearce, A., & Mayho, P. (2004). Provision of antenatal care during Ramadan. British Journal of Midwifery, 12(12), 750-752. [Context Link]


Pinar, R. (2002). Management of people with diabetes during Ramadan. British Journal of Midwifery, 11(20), 1300-1303. [Context Link]


Qaisi, V. G. (2001). Increasing awareness of health care concerns during Ramadan. Journal of American Pharmaceutical Association, 41(4), 511. [Context Link]


Rabinerson, D., Dicker, B., Kaplan, A., Ben-Rafael, Z., & Dekel, A. (2000). Hyperemesis gravidarum during pregnancy. Journal of Psychosomatic Obstetrics and Gynecology, 21(4), 198-191. [Context Link]


Robinson, T., & Raisler, J. (2005). "Each one is a doctor for herself": Ramadan fasting among pregnant Muslim women in the United States. Ethnicity and Disease, 11(Suppl. 1), S99-S103. [Context Link]


Sulimani, R. A. (1991). Ramadan fasting: Medical aspects in health and in disease. Annals of Saudi Medicine, 11(6), 637-641. [Context Link]


The Qur'an. (2007). (Shaheen International, Trans.) Riyadh, Saudi Arabia: AL-Muntada Al-Islami Trust. [Context Link]


Whitelaw, S. (2005). Management of diabetes during Ramadan. Diabetic Medicine, 22(Suppl. 4), 21-23. [Context Link]


Zaidi, F. (2003). Fasting in Islam: Implications for the midwifery practice. British Journal of Midwifery, 11(5), 289-292. [Context Link]