Background: Fasting during Ramadan is compulsory in the Muslim faith. Although pregnant women may be exempted, many still choose to fast because of a confluence of social, religious and cultural factors. Objective: Little is known about the physiological effects of fasting during Ramadan on the mother or unborn baby, and thus nurses and other health-care providers are faced with the difficult task of providing appropriate medical advice to Muslim women regarding the safety and impact of their fasting. In this study, we examined the practice of fasting among pregnant Muslim women in Amol/Iran, and examined their beliefs on fasting during the holy month of Ramadan 2011. Materials and Methods: This is a retrospective study of all Muslim women in Amol who were pregnant and received antenatal care in healthcare center during the month of Ramadan. Exclusion criteria were all women with any problem in pregnancy. A questionnaire was tool of study. Data were analyzed with Statistical Package for the Social Sciences software (SPSS) (P < 0.05). Results: From 250 questionnaires, 215 were responded and collected. 31.8% pregnant women fasted during Ramadan. The average time of fasting was 9.88 days. There was a significant relationship between parity (0.035) and gestational age (0.049) and fasting. 85% of women believed that fasting during pregnancy is a ritual. 71.7% women did not change their prenatal care. 73.5% of pregnant women consulted the obstetrician about fasting. The most common complication in mother was fatigue and weakness. The average size of the head circumference and length of newborn was normal. Conclusion: Midwifes and other health workers need to learn as much as possible about the multicultural best practices and research-driven information about fasting in order to help Muslim women make informed decision.
Keywords: Belief, fasting, manner, Muslims, pregnancy, Ramadan
Fasting in the holy month of Ramadan is one of the five basic pillars of Islam. According to this obligation, Muslims are forbidden from eating and drinking from sunrise until sunset for one month (29-30 consecutive days). ,, Since Ramadan is based on lunar calendar, it may occur in every season of the year. Fasting in this month varies between 12 and 19 hours (according to the season). , This divine obligation has many spiritual, physical, mental and social effects. ,,,
Although fasting in Ramadan is obligatory for all Muslims, various groups are exempted. , Fasting is not necessary during pregnancy and breast-feeding if a mother is worried about the health of herself or her fetus; and she can fast at another time or pay atonement. ,, Although fasting is not necessary during pregnancy, some pregnant women prefer to fast in Ramadan. 
Different studies have been conducted on the effects of fasting based on the health of fetus and mother. In some studies, no significant adverse effect of fasting on maternal or fetal health has been reported. ,,,, However, some studies have shown the negative effects of mother’s fasting on maternal and fetal health. The risk of hyperemesis gravidarum in fasting-women increased.  A significant decrease of glucose, insulin, lactate and carnitine levels and an increase of triglyceride and hydroxybutyrate among fasting pregnant women were demonstrated. Ketonemia and hypoglycemia frequently occurs with more prolonged fasting.  A decrease of fetal breathing movements due to the decreased glucose level in mother and a decrease of fetal biophysical profile score during fasting can indicate that the fetus is at risk.  Ewijik study in Indonesian adults showed that people who were prenatally exposed to Ramadan fasting had a poorer general health than others.  As predicted by medical theory, this effect is especially pronounced among the older people, who also more often report symptoms indicative of coronary heart problems and type-2 diabetes. Among exposed Muslims the share of males is lower, which is most likely caused by death before birth. He showed that these effects were unlikely the result of common health shocks correlated to the occurrence of Ramadan, or of fasting mainly occurring among women who would have had unhealthier children anyway. ,,,
Discussing and consulting pregnant women with regard to safety and risks of fasting is difficult without considering their faith and beliefs.  Yet, some of these pregnant women do not talk with healthcare staff as they are worried about being prevented from fasting.  This study was done to investigate the level of fasting among pregnant women in Amol and examine their beliefs and manners regarding fasting in Ramadan 2011.
This retrospective descriptive study investigated the rate of fasting and beliefs of pregnant women among the women admitted to birth control clinics in the city of Amol from September to November 2011 (3 months after Ramadan). The studied samples included women who were pregnant during Ramadan 2011. Exclusion criteria included mothers with a history of systemic disorder, drug consumption during pregnancy (except for iron, folic acid, multivitamin, and anxiolytics less than 48 hours), smoking, and narcotic.
The sample size of this study was estimated 250 people. A questionnaire was used to collect data. The questionnaire was designed in 3 sections; the first part consisted of demographic characteristics such as age, education, occupation, the number of pregnancies, gestational age, and presence or absence of any diseases along with pregnancy. The second part evaluated the belief and awareness of participants about fasting in Ramadan, which was done using simple yes/no questions. The third part examined fasting manner of the participants regarding nutritional habits and methods and specific cares. After Ramadan, the questionnaire was given to urban and rural health centers of Amol, and after obtaining written consent for participation, it was randomly presented to research units and was collected after completion. The results were studied using SPSS software and statistical tests of t and χ2 at the significance level of P < 0.05%.
Of 250 questionnaires delivered to the research units, 215 were collected. Personal specifications of the participants are presented in [Table 1].
Seventy-three (35.2%) participants in the study stated that they were fasting, 56.3% with mild fasting (1-10 days), 31.5% moderate fasting (11-20 days) and 13% with full fasting (21-30 days). The mean number of fasting days was 9.88 days.
There was no significant relationship between age (P = 0.21), occupation (P = 0.32), place of residence (P = 0.63) and fasting. The mean gestational age of fasting women was less than that of those who were not fasting ( =0.049). The relationship between fasting and parity was significant. That is, multiparous women were fasting more than primiparous women (P = 0.035). 52.6% of the women mentioned that they would feel guilty if they did not fast. 24.4% of the women said that they had to fast to benefit from the spiritual effects of Ramadan and 93% believed that other activities (such as reading Quran and charity) had spiritual effects, as well. The knowledge of women about fasting-law was studied [Table 2].
In the investigation of studied beliefs, 34% believed that fasting would be harmful for mothers, 66.7% believed fasting was dangerous for the fetus and 83.3% told that fasting was more difficult during pregnancy. The activity of 43.5% of the participants did not change by fasting and 71.7% of them did not change their pregnancy care program. 35.4% of fasting women were supported by their family, 87.8% paid attention to the recommendations of health staff about fasting and 73.5% consulted with an obstetrician or midwife. 70.8% served Sahar and Iftar. (well-nutritious). 36.2% had increased food consumption especially tea drinking, water drinking, and sugar consumption.
The reasons of non-fasting and the complications mentioned by mothers are presented in [Table 3] and [Table 4].
The average weight of newborn babies was 3310 ± 616 gm, their length was 48.81 ± 1.75, and head circumference was 34.48 ± 1.62. All these figures are in normal range.
The goal of this study was to investigate fasting in pregnancy. In this study, 35.2% pregnant women were fasting during Ramadan. In a similar study, in Singapore alone, 13% of pregnant women did not fast  and in another study in Iran, 34.9% of mothers did not fast during pregnancy.  The study was conducted in the month of September when the weather was very hot and humid and fasting took 19 hours; therefore, fewer women fasted, and some mothers who fasted delivered in Ramadan and did not come to prenatal care centers after Ramadan. It is essential for health professionals to reduce possible negative impact of fasting. According to most Islamic resources, pregnant women are exempted from fasting in Ramadan. ,,, The reason is the concern about the emergence of problems or complications in mothers and fetuses due to fasting.  According to the hadith quoted by Ibn-Abbas, if a pregnant woman is worried about her health or fetal health during her pregnancy, it is not necessary to fast but she should pay the atonement for all the days.  Islam supports children even before their birth. That is why fasting is not obligatory for pregnant women if they are worried about fetal health. 
In this study, 52.5% of women would feel guilty if they did not fast, and 83.3% told that fasting was more difficult during pregnancy. Despite adverse effects of fasting on maternal and fetal health, some women tend to fast during pregnancy. Their reason is that fasting is simpler along with their families. Fasting alone and on the days other than Ramadan generates less spiritual feeling in comparison with that on Ramadan days. Other reasons for the tendency to fast during pregnancy was the inability to pay the atonement  and finally lack of concern about emergency of any harm or problem for the mother or fetus after fasting.  In the study by Robinson on 32 Muslim women in Michigan State (most of whom were Arab immigrants), 60% were fasting in Ramadan and most of them mentioned that they had fasted two or three days to see whether they were able to fast or not; if not, they gave up. All of them, except 3, believed that fasting was useful for pregnant mothers. They said that everybody could be her own doctor and could decide when to fast and when to break.  Many pregnant women were supported by their family members although they might have no adequate awareness about religious rules. In the study by Josooph, 30% of pregnant women had no exact awareness about fasting rules in Ramadan. 25% stated that fasting during pregnancy was more difficult and stated its different complications; nevertheless, they continued fasting due to their religious attitude, feeling the obligation and influence of family members. 
The gender role of men (father, brother, husband) in decisions of women should be always considered in caring and consulting programs for pregnant women. Increasing the awareness of men and encouraging them to participate in women’s training programs would be more effective in the success of these programs. 
It seems that emergence of fasting complications depends on fasting manner. In healthy pregnant women who receive sufficient food and beverages during Iftar and Sahar meals, especially in the seasons when fasting days are short, fasting would not be problematic. ,, In Azizi’s investigation, significant biochemical changes were observed in the blood of fasting pregnant women though it did not affect the final outcome of pregnancy.  Also, fasting had no influence on the weight and anthropometric measurements of newborn babies. ,, In this study, 46.2% women felt weakness and fatigue and 12.9% felt decreased fetal movements. In Altaani study, non-stress tests are more likely to be non-reactive during the period of fasting, but return to reactivity after dinner.  Consuming food and beverages only for 2 meals during fasting days would increase the likelihood of ketonemia or ketonuria in addition to the risk of hypoglycemia during hunger hours, particularly during hot seasons. ,, Suitable planning for these persons includes increasing prenatal care, frequent urine tests for checking ketunoria or bacteriuria, fetal well being tests and nutritional consulting programs. , Nutritional recommendations for preventing from hypoglycemia include a varied and healthy diet which does not contain a high amount of sugar. Compound carbohydrates increase blood sugar more slowly and prevent from hypoglycemia. Moreover, consuming high amounts of caffeine (tea and coffee) during pregnancy has long-term effects on the health of babies. 
Healthcare staff should adopt acceptable policies to offer effective and suitable services considering medical, social and economic aspects. ,
Robinson and Restler developed specific guidelines for healthcare providers aimed at improving the quality of care of fasting pregnant mothers. Their guidelines included:
Ramadan fasting is important to Muslim patients, including pregnant women as it narrows value fasting as a practice that contributes to their spiritual, psychological, physical, and social health. The informed prenatal health provider should work with her /his Muslim patient in a manner that respects their desire to fast while helping them ensure its safety. When fasting is high risk, the health provider should address this concern with sensitivity and compassion, providing ample evidence to support her recommendation.
The authors appreciate the attendance of all pregnant women who participated in this study and midwives of healthcare centers in city of Amol who cooperated in data collection.
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4]