By Dr Ariza Mohamed
Consultant Obstetrician & Gynaecologist , Ampang Puteri Specialist Hospital
Ramadhan is just round the corner.!! Even if one doesn’t follow the Islamic calendar, one would still know that Ramadhan is just round the corner because some shopping centres are already blasting out Raya songs! It’s probably only in Malaysia that people ‘miss’ out the Ramadhan month and instead celebrate Idul Fitri a month earlier.
For the pious, Ramadhan is revered and very much anticipated. The ‘waiting’ for Ramadhan usually starts from the Rejab (Islamic calendar) which corresponds to the last week of June. The Prophet has taught Muslims to recite the prayers which goes something like this…’ Dear Allah, bless us in our Rejab and bless us in our Sya’aban and may we arrive in Ramadhan’.This is due to the feeling of fear of not being able to celebrate Ramadhan as well as hoping very much that one’s life is prolonged to be able to achieve the blessings and forgiveness from Allah during the coming Ramadhan.
The purpose of this article is to give a wider horizon for the practising Muslim doctors on how to handle their pregnant and nursing mothers and also to give some insights to our Non-Muslim doctors on why Muslims fast and also to give them some information probably needed as they handle their pregnant and nursing Muslim patients.
The Muslims are ordained to fast during the whole of Ramadhan when surah Al-Baqarah Verse 183 was revealed to Prophet Muhammad.
‘Oh you who believe! Observing As Shaum ( the fasting) is prescribed for you as it was prescribed for those before you, that you may become Al-Muttaqun (the pious) ‘ (Al- Baqarah : 183)
Fasting is compulsory for all Muslims who has reached puberty. Muslims all over the world fast the whole of Ramadhan in submission to Allah. Although fasting has been shown to have many health benefits, this is not the reason why Muslims fast. Fasting is one of the five pillars in Islam and is compulsory.
However, some group of people are given exemption from fasting as the following verse showed:
“Fasting for a fixed number of days, but if any of you is ill or on a journey, the same number ( should be made up) from other days. And as for those who can fast with difficulty,(eg old man), they have a (choice either to fast or) to feed a poor person for (every day). But whoever does good of his own accord, it is better for him.And that you fast is better for you if only you know”
(Al Baqarah : 184)
The few groups given exemption are those who are ill, or is on a journey. For these group of people, the verse clearly says they are exempted from fasting but should replace the number of days missed in other months.
Let’s look at one seerah- Rasulullah was at one time making a journey during Ramadhan with the sahabah. Some sahabah chose to continue fasting and some sahabah chose not to fast. The Prophet Muhammad has also been noted to break fast while on a journey.
Some people argue that travelling now is already so convenient and comfortable that Muslims who chose not to fast were sometimes frowned upon. However, this (breaking fast) should be taken as following the sunnah/ways of Rasulullah and should be commended. Just like how prayers can be shortened and combined during travelling, irrespective of whether the journey undertaken now is so much more pleasant compared to before.
Of course those who do not fast will need to ‘pay back’ when Ramadhan is over ,ie to fast the same number of days that he had missed.
Menstruating women and women in confinement are not allowed to fast. Seeing from the medical point of view this is good for the menstruating women and those in their postpartum period as she would be losing some blood and it will be for her benefit to eat and have her iron supply replaced. Although personally we know of some women who took pills to stop her menses during Ramadhan so as she could fast the whole month! How Islam looked at this need to be further discussed.
We know that the sick are not required to fast. What about pregnant and nursing mothers? Are they considered sick?
Pregnant and nursing mothers are not ‘sick’, they are in fact healthy women undergoing a normal process in life. And so they don’t fall under the sick category .
However, in the same verse, it also says…’ and for those who can fast with difficulty, they have a choice either to fast or to feed a poor man every day ( that they missed).’
Let’s look at a nursing mum. When a mother is fasting, would it affect the quantity and the quality of her milk? The quantity might be affected. What about the quality? Some party claimed that the quantity as well as the quality of breast milk is not affected even in women in war-torn countries whom are deprived of good nutrition.
If the baby is still fully breast feeding and has not been weaned yet, the baby will depend wholly on the breastmilk produced by his mother. A fasting mum who finds that her baby is feeding well even when she is fasting could continue to fast. However if a mum finds that she is producing less and the baby is showing signs that he is not getting enough from breastfeeding could opt not to fast. On the other hand, if the mother insist on fasting, she might want to stop breastfeeding or will want to mix feeding with bottlefeed /infant formula and this is not encouraged. The WHO has stated that babies should be exclusively breastfed for the first 6 months to achieve the full benefit of breastfeeding. A mum who continue fasting would be doing so at the expense of her baby being introduced to cow’s milk /infant formula which is less healthy for the baby. A baby who is denied full breastfeeding will be at a higher risk for infection compared to one who is fully breastfed. On top of that, breastfeeding mum who fasted reported feeling lethargic and exessive hunger and this is probably due to dehydration.
So, should a breasfeeding mum fast?
According to the ulamas, the term….‘those who can fast with difficulty..’ here includes nursing mum. Although she can fast, it will be with a lot of difficulty since the baby will require to breastfeed every few hours and this in turn will make the new mum dehydrated and lethargic.
In my opinion, a nursing mother whose baby is below 6 months and is not weaned yet, need not fast if she feels worried that her baby might not be getting enough milk or she feels exessively lethargic. However, mothers whose babies are already on other form of food and not fully dependant on breastmilk should continue to fast . Mums who find that their babies are well fed and they are not excessively lethargic also should continue fasting.
What about a pregnant mother then?
A pregnant mother, as we all know, will experience symptoms of pregnancy especially in the first three months.
During these period, some women face a lot of difficulties with vomiting and coping with tiredness. Usually doctors would encourage them take small frequent meals as to try and reduce vomiting. There’s no known “cure’ for hyperemesis gravidarum, with anti emetics like maxolon most of the time not really effective. Therefore , encouraging the patient to have frequent sips of water is important to avoid dehydration and need for parenteral iv infusion.
These category of mother clearly falls under the ‘ fasting with difficulty’ category and according to Islam , don’t need to fast.
Mothers who are in their second and third trimester are usually happy, healthy and buoyant (well…most are..). therefore , they have a choice to fast or not to fast. If they feel easily tired, bearing in mind that mothers now are mostly career women, then they have a choice not to fast.
The ulamas are in agreement that nursing and pregnant mothers are given this very special exemption.They are also in agreement that if the mother worries about the health of her baby, or if there’s any reason at all for the doctor attending her to suspect possible harm on the baby, then the woman should not fast. Therefore, any woman with Diabetes on treatment or hypertension or IUGR etc need not fast and need not have their medication adjusted. I think this is the challenge that we usually face in pregnant mothers with medication who wishes to fast during Ramadhan.
But does fasting have any effects at all on the fetus?
A few groups of doctors in Turkey had looked at women fasting in Ramadhan and measured the fetal parameters (BPD,FL,EFW) and fetal well being (BPP,AFI,Doppler). They found no maternal ketonemia or ketonuria and no significant adverse effect on intrauterine fetal development or fetal health.( J Obstet Gynaecol Res.2008 Aug:34(4): 494-8.) Others who did similar studies also found no significant effect on fetal health. My own personal observation on my patients found that none had problem of IUGR or slower growth due to fasting.
Even though mothers are given flexibility in fasting during pregnancy, most usually insist on fasting. Why? Well, I feel that apart from the genuine yearning for ‘pahala’ that one gets with fasting, mothers are also worried that they have to ‘pay back’ so many days of Ramadhan missed.
The ulamas are in consensus that fasting and breastfeeding women can break their fast. However there are different opinions on how to replace the missed days. They are a few views on this .
Some say they need to replace their fasting in other months the same number missed during Ramadhan. For example, if she missed 10 days, then she had to fast 10 days outside Ramadhan. (according to Imam Hanafi)
Some ulama says, just feeding a poor man the same number of missed days, ie missed 10days, so feed a poor man 10 days or give food to 10 men/women.
Some says, both need to be done.
Some says, none need to be done.
The common practise by Malaysians is to replace the missed fastingdays ( for mum who worries about herself) and on top of that to feed the poor if mum is worried about her baby. ( Imam Shafie and Imam Ahmad)
However, according to Ibnu Abbas and Ibnu Umar, which were renowned Islamic scholars, the second option ie feeding a poor man without needing to replace the days with fasting on other month is more appropriate. (reference:translation of FIQH Sunnah-by Sayyid Sabiq, volume 3)
Generally in Malaysia, Muslims follow rulings by Imam Shafie ie replacing back lost days by fasting on other days in other months. The decision to follow one Imam is to ensure uniformity and to reduce confusion amongst the less knowledgeable.
However, it is good for Muslims to know that they are other ‘school of thoughts’ regarding how to replace lost days during Ramadhan. All these ‘school of thoughts ‘are acceptable as all are ‘evidence-based’ ie they are all based on Al Quran and sunnah with different interpretation.
As for me, this is a new information which I had gathered while writing this article. Women in Malaysia had generation after generation ‘paid back’ their missed fasting days with fasting in other months. And from my experience,it is not easy to repay back 30 days of fasting if you missed the whole month! Fasting one month in Ramadhan cannot be compared to fasting in other months, since fasting in Ramadhan is lots lots easier ( and of course fasting in Ramadhan gives you a lot of ‘pahala’ or returns)
If I had a choice, I certainly would rather feed a poor man…..furthermore, the baby will be breastfeeding sometimes up to a year and the mother will still have difficulty to ‘pay back’ her fasting, and before you know it, the next Ramadhan comes or the mother gets pregnant again!!
Anyway, as Allah says in the subsequent verse, he intends for us ease,and does not want to make things difficult for us.
‘ The month of Ramadhan in which was revealed the Quran, a guidance and the criterion between right and wrong. So whoever of you sights the crescent on the first night of Ramadhan, he must observe shaum (fasting) that month, and whoever is ill or on a journey, the same number of days must be made up from other days. Allah intends for you ease, and He does not want to make things difficult for you…………’
Al baqarah 185
Islam is a religion which is easy to practice and we should not make it difficult. With that, to all Muslims, a happy and Blessed Ramadhan.