Fasting during pregnancy

[This was originally an extended postscript on last week's post, "Yuletide musings on the Ramadan shutdown," but I think the topic warrants its own post and these long postscripts on tangents are distracting. When I have a chance, I'll try to beef it up by adding some links to studies. For now, here is the earlier comment, unedited.]

This is a bit of a tangent, but I have to say that I think it’s disgraceful how–in this day and age, when new evidence comes out every day showing the serious and multifaceted impact of maternal diet and environmental factors on children’s births and long-term health–Muslim women are often encouraged to fast during pregnancy. According to some reports, around 90% of pregnant women fast in Muslim-majority countries, a statistic that becomes all the more alarming when you consider how hard these environments already are in many cases, thanks to poverty, poor sanitation, lacking infrastructure and other challenges that plague developing countries.

Now, there is admittedly some debate among doctors and statisticians about this matter, but there is no shortage of credible research indicating that fasting may be harmful for babies. And this certainly jibes with common sense, given the mountain of evidence that vitamin deficiencies and careless eating harm even adults in a myriad of ways. We shouldn’t be rolling the dice with our children’s health, especially while we’re otherwise stocking up on vitamin supplements for ourselves.

We need leadership from Muslim leaders and scholars on this so that mothers will feel comfortable bucking this taboo. If you ask me, if there is to be any pressure here, it should be on women not to fast. What’s more, in light of these medical concerns, perhaps the Fuqaha will ultimately need to take more radical action, exempting pregnant women entirely from the traditional requirement to make up missed fasts. Otherwise, a different sort of pressure remains and some mothers may choose to “get it over with” at the expense of their unborn child (and, before I get lectures on the joys and blessings of fasting and how one shouldn’t discuss fasting as a burden, the reality is that many people–being human–are eager to return to normal life, don’t want to fast alone afterwards, and/or don’t have the money to feed others; any serious attempt to discourage risky fasting would need to take those factors into account).

Finally, call me a modernist subversive, but I have to admit to never having found justifications for the expectation that pregnant will make up missed fasts satisfying in the first place. Salat (daily prayers) are no less integral a part of being a Muslim–both are “pillars” of the faith, after all–and pre-menoposal women are not expected to make up the significant number of prayers they miss each month due to menstruation. I’m sure many women who would be eager to make up the fast for purely spiritual reasons–in like vein, my wife greatly misses making salat during those times of the month–but a new mother has a lot to deal with as it is. Why not make it entirely optional?

Update (Jan 3, 2013): As promised, here are links to some relevant articles and papers. As is often the case in the early stages of health research, there are dueling findings. Some studies seem to demonstrate a link between such fasting and bad outcomes or risky conditions; others find no statistically significant effect.

Each study has an abstract section that sums up the findings.

If there’s one time to err on the side of caution, though, I sure think it’s during pregnancy.

The question was also discussed in a chapter in the bestseller by Steven D. Levitt & Stephen J. Dubner, Super Freakonomics: Global Cooling, Patriotic Prostitutes, and Why Suicide Bombers Should Buy Life Insurance.

Here is one blogger’s summary of why the concerns being raised, while not conclusive, deserve attention:

Doug Almond has turned out an impressive amount of work in recent years on how bad stuff that happens to fetuses early in pregnancy can cause long-lasting problems. His first paper on this (AER 1985) showed that babies who were in utero during the 1918 American flu pandemic “displayed reduced educational attainment, increased rates of disability, lower income, and lower socioeconomic status.”

In the last year, he has produced two more papers in this area (AEJ Applied 2011, NBER Working Paper 17713) that focus specifically on the long-term effects of the fasting of pregnant Muslim women during Ramadan. And one of his co-authors (Reyn van Ewijk) has a forthcoming paper in the Journal of Health Economics on this topic as well. While none of the papers is truly convincing on its own, taken together, the results are striking. In Michigan, England, and Indonesia, Muslim babies who were in their first trimester during Ramadan go on to experience worse health and schooling outcomes than other babies.

What’s surprising about this finding is that the Koran specifically states that pregnant women are exempt from fasting during Ramadan if the health of their baby is at risk. Van Ewijk’s paper has a terrific background section where he explains that in fact most pregnant Muslims from around the world do tend to fast during Ramadan. [MORE]

  • Svend White

    Pay this no mind. These aren’t the droids you’re looking for. This comment is just here so that I can reply to it. It has to do with how the WordPress admin page works.

    • Amy

      Interesting you should bring up fasting in pregnancy. Some female friends and I had a conversation about it last Ramadan. Among the five of us, some converts and some not, we found that this issue seems to follow family lines. I’m an American married to a Pakistani, and in my husband’s family no one fasts during pregnancy, and neither did I. But that wasn’t the case for some of the others–in their families or husbands’ families, there is strong peer pressure for the pregnant to fast, at least some of the time. Frankly, I don’t know how anyone manages it in pregnancy, between the nausea and the exhaustion. During my pregnant Ramadans, I did miss the feeling of participation and the breaking fast together, but I also found a lot of satisfaction (and inshallah, blessings) in feeding fasting people.

      • Svend White

        Salaams and thanks for sharing, Amy. I am married into a Pakistani family, too, and I know of one case where a sister-in-law (a doctor, ironically) fasted during pregnancy. Don’t know what trimester she was in.

        I have no idea about the reliability of that breakdown–that number was just what I read in an article–but I wouldn’t be surprised if holds true, especially in rural areas.

        I can imagine that some people will laugh and say something to the effect of “Oh, rich white people and bourgeois preoccupations!”, but nutritional needs are obviously biological in nature and transcend culture or place. A child that doesn’t get what it needs to develop properly will have the resulting complications whether in Manhattan or the Ferghana Valley. (Look at all the evidence that breastfeeding has a long-lasting affect on children’s health. Imagine the consequences of nutritional deficiencies when a baby’s very organs are developing. I don’t even like to think about it.)

        Now, in a First World context (or in well-to-do circles in developing countries), I can see how it *might* be potentially safe, assuming care was taken to compensate at the end of the day and attention were paid to the child’s stage of development. However, given how careless and/or poorly informed people often are about health matters (e.g., just take the studies showing that most people, insanely, don’t even both to wash their hands unwashed after using public bathrooms, which positively teem with germs; or the sizable number of parents in America who use things like Mountain Dew as baby formula, rotting their teeth and doing God knows what else), I’m not sanguine about fasting even in those situations.

        And in the non-elite, developing world contexts in which most Muslims live, I think it’s medically speaking freaking insane. I don’t blame the women–they’re just abiding by the rules of the culture they operate under and/or may be unaware of the potential for complications–but that doesn’t change the consequences. In places where healthy food isn’t readily available to begin with (whether due to shortages or because food consumes much more of people’s income; while in the USA people spend something like %15 of their income to feed themselves, people in developing societies often pay 50-70%), where neonatal health infrastructure and services are severely limited (or perhaps non-existent), and where many people simply aren’t “literate” concerning health and nutrition, it’s a recipe for disaster. Who knows how many health complications would have been avoided or mitigated?

        NGOs can only do so much. A lot of this will depends on Muslim leaders on the ground repudiating the stigma that non-fasting mothers face.

      • Svend White

        Mentioned this to my wife and she thought I was overdoing it. Maybe, but then one often hears how American-born children of immigrants from developing countries tend to be larger their parents with reference to, among other things, better nutrition. In other words, people’s growth is not infrequently stunted to some extent by the conditions they find themselves in. If adults are affected this way when they are eating normally, I have to wonder about the affect of fasting on fetal development. Better safe than sorry, I say.

      • Svend White

        On the issue of peer pressure, my wife said she suspected it was more a desire to avoid having make up the fast later, which is a very interesting point. She also said that far from being the repository of piety, in Pakistan villages are places where people make moonshine and engage in all sorts of other impious shenanigans that more educated city folk would frown upon. Also an interesting point.

        I realize that religious norms are sometimes enforced less assiduously in rural environments–you sometimes see more pragmatism and syncretism in village culture–but I wonder about the extent to which that holds true across the Muslim world. Perhaps Pakistan’s bacchanal villages are a bit of an anomaly?

        Also, even if many people in such environs are indeed less religiously observant to one extant or another, I’ve often observed Ramadan being enthusiastically observed by otherwise nonpracticing Muslims (it’s both a nostalgic tradition and a way of participating in communal life). And, even if there is no conscious pressure on the part of the community, women might feel pressure to fast, anyway, when there is no general awareness of it being important for mothers to dispense with fasting for their babies’ sake.

        • Amy

          The point about not wanting to have to make up the fast later is well taken. I know women who take birth control pills in Ramadan to avoid menstruating and having to make up those fasts.

          But the peer pressure is real, at least among women I know. Their husbands or sisters-in-law will say, “So you’re gonna fast, right?” or “You’re not fasting? Even a couple of days a week?” I once heard a scholar say that every pregnant woman should fast at least during the first trimester. (I can only assume he’s not married, or he would know that nausea makes that virtually impossible for many women!)

          Svend, if you have any links to studies regarding impact of fasting on fetuses, could you post them? My friends and I were arguing about that, with some insisting that it’s fine as long as you more or less reverse your days and nights, getting hydration at iftar, late night, and early morning.

          • Svend White

            I’m adding some links now.

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  • Zack

    I agree completely, Svend.

    As I argued many years ago, the idea of requiring women to make up fasts missed due to pregnancy and breastfeeding is problematic too since it looks at pregnancy and breastfeeding like a short-term illness.

    A child’s most important years are the ones in the womb and infancy. It’s important to give the child the best nutrition possible during that period.

    • Svend White

      Thanks, Zack. That was an interesting discussion. I have to say that I agree that it seems unfair to expect pregnant women to make up their fast (and just added a snippet to this post to that effect).

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