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.

• John F Trepanowski and Richard J Bloomer. “The impact of religious fasting on human health”
  Nutrition Journal 2010, 9:57
• Douglas Almond & Bhashkar Mazumder. “The effects of maternal fasting during Ramadan on birth and adult outcomes”
  Working Paper Series WP-07-22, Federal Reserve Bank of Chicago.
• Douglas Almond & Bhashkar Mazumder & Reyn van Ewijk. “Fasting During Pregnancy and Children’s Academic Performance”
  NBER Working Papers 17713, National Bureau of Economic Research, Inc.
• J H Cross, J Eminson, and B A Wharton. “Ramadan and birth weight at full term in Asian Moslem pregnant women in Birmingham.”
  Archives of Diseases in Childhood. 1990 October; 65 (10 Spec No): 1053–1056.
• J Awwad, IM Usta, et al. “The effect of maternal fasting during Ramadan on preterm delivery: a prospective cohort study” (pay-walled; summary available here)
  BJOG: An International Journal of Obstetrics & Gynaecology. 2012 October; 119(11):1379-1386.
• Sarita Bajaj, Afreen Khan, et al. “South Asian consensus statement on women’s health and Ramadan”
  Indian Journal of Endocrinology and Metabolism. 2012;16(4):508-511
• Malihe Arab & Shahla Nasrollahi. “Interrelation of Ramadan Fasting and Birth Weight”
  Medical Journal of Islamic Academy of Sciences 14:3, 91-95, 2001
• Reyn van Ewijk, 2009. “Long-Term Health Effects on the Next Generation of Ramadan Fasting During Pregnancy,”
  CEP Discussion Papers dp0926, Centre for Economic Performance, LSE.
• Sean Cassidy & Jerome Taylor. “Pregnant women who fast for Ramadan risk damage to their babies, study finds”
  The Independent 2010
• SH Alwasel, Z. Abotalib  et al. “Changes in Placental Size during Ramadan.”
  Placenta 2010;31:607-10.
• Suha Al-Oballi Kridli. “Health Beliefs and Practices of Muslim Women During Ramadan”
  MCN, The American Journal of Maternal/Child Nursing, July/August 2011

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]