Experiences and outcomes of maternal Ramadan fasting during pregnancy: results from a sub-cohort of the Born in Bradford birth cohort study

Dietary diversity and other predictors of low birth weight in Gurage Zone, Ethiopia: Prospective study

BACKGROUND

Low birth weight (LBW) is a major public health problem in Ethiopia. Dietary diversity is a key indicator of maternal dietary adequacy that may affect birth weight but little is known about their relationship. Hence, this study aimed to assess the association of suboptimal maternal dietary diversity during pregnancy and low birth weight in Gurage Zone, Ethiopia.

METHODS

The prospective study was conducted among 1062 pregnant women enrolled consecutively in between 16 to 20 gestational weeks and followed until delivery. The baseline data were collected at recruitment and dietary diversity was assessed using the minimum dietary diversity score for women (MDD-W) tool in three different rounds. The average of three scores was considered to categorize women into optimal (consumed ≥ 5 food groups) and suboptimal (consumed < 5 food groups) dietary diversity groups. The risk of low birth weight among suboptimal dietary diversity was assessed using modified Poisson regression with robust standard error.

RESULTS

Of the 1062 pregnant women recruited, 959 (90.4%) women completed follow-up. Among them, 302 (31.5%) women are having optimal and the rest, 657 (68.5%) women are having suboptimal dietary diversity. The risk of low birth weight was significantly higher among women with sub-optimal dietary diversity than among those with optimal diversity (ARR = 1.89, 95% CI: 1.25, 2.84). Other factors such as rural residence (ARR = 1.61, 95% CI: 1.43, 1.87), age > = 35 years (AAR = 3.94, 95% CI: 2.41, 6.46), being underweight (ARR = 1.81, 95% CI: 1.14, 2.86), height < 150cm (ARR = 4.65, 95% CI: 2.52, 8.59), unwanted pregnancy (ARR = 3.35, 95% CI: 2.23, 5.02), preterm delivery (3.65, 95% CI: 2.27, 5.84) and lack of nutritional counseling (ARR = 1.69, 95% CI: 1.08, 2.67) significantly increased the risk of low birth weight.

CONCLUSION

Suboptimal dietary diversity associated low birth weight. Promoting dietary diversity by strengthening nutritional education and avoiding unwanted pregnancy particularly among rural residents may help to reduce the incidence of low birth weight.

Effect of Ramadan Fasting in Turkey Upon Fetal Well-being and Perinatal Outcomes During the Last-Trimester of Pregnancy

Ramadan, a one-month period in which eating and drinking are prohibited from sunrise to sunset, is considered sacred by Muslims. According to Islamic rules, fasting is obligatory for adults and healthy people, but patients and travelers are exempted from this rule. It is not clear whether pregnant women can fast during Ramadan. This cross-sectional case-control study included low-risk pregnant women at 32-37 weeks of gestation in Turkey. We examined healthy women in the last period of their pregnancy and found similar perinatal outcomes between the fasting and nonfasting participants. In the evaluation of fetal well-being, a decrease in the number of accelerations in the non-stress test (NST) and the need to repeat the test were found to be statistically significantly higher in fasting pregnant women. We consider that this may prolong the evaluation period and increase unnecessary hospitalizations due to nonreactive NST results. More randomized controlled trials are needed to conclude that fasting during pregnancy is safe.

Ramadan during pregnancy and neonatal health-Fasting, dietary composition and sleep patterns

BACKGROUND AND OBJECTIVES

Large shares of pregnant Muslims worldwide observe the Ramadan fast. Previous research showed that Ramadan during pregnancy is associated with adverse offspring health outcomes lasting throughout the life-course. Evidence on effects on birth outcomes is inconclusive, however, and previous research did not consider the role of dietary composition and sleep patterns during Ramadan. This study systematically documents maternal lifestyle during Ramadan and assesses if diet and sleep adaptations to Ramadan, independent of and in addition to maternal fasting, are associated with neonatal health outcomes.

METHODS

This study reports a survey of 326 Muslims who delivered their baby in Mainz, Germany, linked to maternal & infant hospital records. Participants reported on fasting, dietary composition and sleep schedules while pregnant during Ramadan.

RESULTS

Fasting during pregnancy was associated with reduced birthweight, in particular for fasting during the first trimester (-352ˑ92g, 95% CI: -537ˑ38; -168ˑ46). Neither dietary composition nor altered sleep were directly associated with birthweight. However, dietary composition during Ramadan outside of fasting hours seems to moderate the fasting-birthweight association, which disappeared for women switching to high-fat diets.

CONCLUSIONS

The finding that dietary intake during Ramadan potentially moderates the fasting-birthweight association is of high relevance to pregnant Muslims who wish to fast and their healthcare professionals, since dietary choices outside of fasting hours are often relatively easily modifiable. This is the first study to include information on maternal diet and sleep during Ramadan, and additional research is needed to assess the roles of specific (macro)nutrients and food groups.

Chrononutrition during Pregnancy and Its Association with Maternal and Offspring Outcomes: A Systematic Review and Meta-Analysis of Ramadan and Non-Ramadan Studies

Much evidence suggests that food intakes and eating patterns are major determinants of the phase of peripheral circadian clocks, and desynchronization between them is thought to contribute to the development of metabolic disorders. However, much remains to be understood about how different dimensions of chrononutrition during pregnancy affect pregnant women's and their offspring's health outcomes. Therefore, we systematically reviewed and integrated all emerging evidence on chrononutrition during pregnancy (including meal skipping, meal frequency, night eating, and (Ramadan) fasting) and their relationships with maternal and offspring outcomes. The results suggest that meal skipping and night eating during pregnancy were generally associated with adverse pregnancy and birth outcomes, whereas no strong conclusion could be reached for meal frequency. In our meta-analysis, Ramadan fasting did not seem to be related with birth weight or gestational age at birth, but evidence for other mother-offspring outcomes was inconsistent. To further elucidate the effect of chrononutrition factors on maternal and offspring health outcomes, larger and well-conducted prospective cohort and interventional studies are needed. In addition, information on covariates such as physical activity, sleep, diet quality and quantity, fasting days, fasting period per day, and trimester exposure should also be collected and considered during analysis.

In utero Ramadan exposure and child nutrition

In this study, we empirically analyse whether in utero exposure to the Ramadan fasting period is negatively associated with child nutrition. The data for the analyses come from a retrospective assessment of 759,799 children from 103 Demographic and Health Surveys (DHS) across 56 countries during 2003-2020. Considering the month-long Ramadan exposure as a natural experiment, we implement an intent-to-treat framework, comparing stunting and underweight among children aged 0-5 years who were exposed to Ramadan fasting at any time in utero with those who were not exposed. Our findings do not show significant evidence to conclude that in utero exposure to the Ramadan fasting period is negatively associated with child nutrition. On the contrary, except for stunting in Muslim children who had in utero exposure to Ramadan fasting during the first months of pregnancy, we find no significant association between in utero exposure to Ramadan fasting and child stunting and underweight. Our main results are robust to multiple robustness checks.

Ramadan Fasting as a Religious Obligation: A Qualitative Study on Opinions and Experiences of Muslim Pregnant Women about Fasting in Turkey

The aim of this study was to examine opinions and experiences of Muslim pregnant women about Ramadan fasting in Turkey. The study had a descriptive, phenomenological design and included 17 Muslim pregnant women living in Turkey. Content analysis and word cloud analysis were performed. The content analysis revealed two themes. The most frequent words in the word cloud analysis were fasting, pregnancy, Ramadan, fast, religious duty, health, observing a missed fast, relief, concern, baby, thirsty and hungry. The findings of the study showed that religious beliefs, experiences, family and society pressured the pregnant women to keep Ramadan fasts. However, due to feeling worried about their own physical and psychological health and their infants, some of the women did not go on a fast. It can be recommended that pregnant women wanting to keep their fasts should be offered information about possible risks of fasting.

Ramadan and gestational diabetes: maternal and neonatal outcomes

AIMS

The impact of Ramadan exposure to Gestational Diabetes Mellitus (GDM) pregnancies is not known. We therefore aimed to assess the association of Ramadan with maternal and neonatal outcomes among pregnant women with GDM.

METHODS

Retrospective cohort study of 345 Muslim women with singleton pregnancies who attended a major Sydney teaching hospital during the period 1989-2010, was undertaken. Exposure to Ramadan was stratified by the: (1) total pregnancy days exposed to Ramadan, (2) duration (hours) of daily fasting and (3) trimester of exposure. Maternal and neonatal outcomes were examined by exposure status, and never exposed pregnancies were comparator in all three analyses. Fasting status was not recorded.

RESULTS

We found no significant effect of Ramadan exposure on mean birthweight, macrosomia and maternal outcomes. However, we found a significant trend for increased neonatal hyperbilirubinemia with increasing Ramadan days exposure and later trimester exposure (p_trend ≤ 0.02 for both), with adjusted OR 3.9 (p=0.03) for those with ≥ 21 days exposure to Ramadan and adjusted OR 4.3 (p=0.04) for third trimester exposure. Conversely longer Ramadan exposure and late trimester exposure were independently associated with a lower prevalence of neonatal hypoglycaemia (adjusted OR 0.4 and 0.3 for ≥ 21 days and third trimester exposure, respectively). Furthermore, neonatal hypoglycaemia decreased for the fasting period of > 15 h group (adjusted OR 0.2, p = 0.01).

CONCLUSIONS

Ramadan exposure is associated with reduced neonatal hypoglycaemia, with no effect on birthweight, implying more favourable glycaemic control. However, the fourfold excess of neonatal hyperbilirubinemia indicates a need for further study of Ramadan and GDM.

Ramadan Fasting and Maternal and Fetal Outcomes in Pregnant Women with Diabetes Mellitus: Literature Review

There is an emerging Muslim and diabetic population in the United States and other Western countries and majority of pregnant women and patients with diabetes mellitus choose to fast during Ramadan. Fasting during Ramadan in pregnant women with diabetes may represent a 'perfect storm' of metabolic disturbances including hyperglycemia, hypoglycemia and ketosis. Recent continuous and flash glucose monitoring data suggests increased glycemic variability (fasting hypo- and post-Iftar hyperglycemia) in non-pregnant patients with diabetes during Ramadan. Only five small-scale studies, predominantly focused on women with gestational diabetes mellitus in Muslim-majority nations have explored maternal glycemic outcomes during Ramadan which is associated with lower mean blood glucose levels and higher frequency of fasting hypoglycemia. Data is limited however on important clinical outcomes such as symptomatic and serious hypoglycemia requiring hospitalization. Results have been conflicting regarding maternal Ramadan fasting and association with fetal outcomes in women without diabetes. Only one recently published study reported on perinatal outcomes in pregnant women with gestational diabetes which found no effect of Ramadan exposure on mean birthweight or macrosomia frequency but lower neonatal hypoglycemia prevalence, however a significant limitation was lack of documentation of maternal fasting status. At this stage, due to paucity of data, the current medical recommendation is against Ramadan fasting for pregnant Muslim women with diabetes. Large-scale population-based studies are warranted regarding maternal and fetal outcomes in pregnant fasting women with diabetes and such studies should characterize maternal fasting status and have meaningful and consistent clinical outcomes. High-quality data derived from these studies can assist clinicians in providing more evidence-based advice to safely navigate both mother and fetus through a potentially challenging pregnancy.

Ramadan exposure during early pregnancy and risk of stillbirth in Arab women living in Canada

BACKGROUND

Data on fasting during Ramadan and the risk of preterm birth and child mortality are conflicting, but the association with stillbirth is unknown.

OBJECTIVE

We studied the relationship between Ramadan and the risk of stillbirth for Arab women in Quebec, Canada.

METHODS

We conducted a retrospective cohort study using birth certificates for Arab women in Quebec, Canada, between 1981 and 2017. The exposure was Ramadan in the first and second trimester (1-27 weeks of gestation), and the outcome was early (<28 weeks) or late (≥28 weeks) stillbirth. We used log-binomial regression models to estimate risk ratios (RR) and 95% confidence intervals (CI) for the association between Ramadan and risk of stillbirth. We adjusted models for maternal characteristics and assessed associations by cause of death.

RESULTS

The study included 78,349 live births and 274 stillbirths. There were 3.5 stillbirths per 1,000 pregnancies for women exposed to Ramadan between weeks 1-27 of gestation (95% CI 3.0, 4.0), and 3.4 per 1,000 for unexposed women (95% CI 2.8, 4.1). Compared with no exposure, Ramadan between weeks 1-27 was not associated with the risk of early (RR 1.32, 95% CI 0.76, 2.28) or late stillbirth (RR 0.93, 95% CI 0.70, 1.23) in adjusted models. RRs for early stillbirth were 1.40 for Ramadan between weeks 15-21 (95% CI 0.70, 2.80) and 1.38 for Ramadan between weeks 22-27 (95% CI 0.67, 2.84). Relative to no exposure, Ramadan between weeks 15-21 was associated with early stillbirth due to congenital anomaly (RR 3.96; 95% CI 1.35, 11.57) in unadjusted models. There was no association with other causes of stillbirth.

CONCLUSIONS

There is no evidence that Ramadan is associated with the risk of early or late stillbirth overall. Further research is needed to confirm an association with stillbirth due to congenital anomalies.

Development of national dietary and lifestyle guidelines for pregnant women in Lebanon

Although a number of international diet and lifestyle guidelines during pregnancy (DLGP) exist in the literature, contextualization to low- and middle-income settings is less common. The aim of this study was to present the Lebanese DLGP and to describe the process followed for their development. A mixed-method approach was used including a review and synthesis of existing international DLGP and a consensus building nominal group technique (NGT) with a multidisciplinary group of experts (n = 11). During the meeting, participants identified the themes of the guidelines, formulated the wording of each themes' guideline and translated the guidelines to the Arabic language. Consensus was defined as an agreement of 80%. Reviewing the literature, a list of 17 main topics were found to be common themes for the DLGP. For the Lebanese DLGP, participants in the NGT meeting selected seven themes from this list: gestational weight gain, diet diversity, hydration, food safety, harmful foods, physical activity and breastfeeding. In addition, the group formulated three themes based on merging/modifying existing themes: supplementation, alcohol and smoking and religious fasting. Two context-specific new themes emerged: wellbeing and nutrition resilience. For each of the identified themes, the group agreed upon the wording of its guidelines and description. This study is the first from the Eastern Mediterranean Region to develop through consensus building, context and culture-specific dietary and lifestyle guidelines for pregnant women. Putting maternal nutrition at the heart of tackling malnutrition and its detrimental health outcomes is a core investment for a better maternal and child health.

Ramadan Fasting during Pregnancy and Health Outcomes in Offspring: A Systematic Review

Ramadan is one of the five pillars of Islam, during which fasting is obligatory for all healthy individuals. Although pregnant women are exempt from this Islamic law, the majority nevertheless choose to fast. This review aims to identify the effects of Ramadan fasting on the offspring of Muslim mothers, particularly on fetal growth, birth indices, cognitive effects and long-term effects. A systematic literature search was conducted until March 2020 in Web of Science, Pubmed, Cochrane Library, Embase and Google Scholar. Studies were evaluated based on a pre-defined quality score ranging from 0 (low quality) to 10 (high quality), and 43 articles were included. The study quality ranged from 2 to 9 with a mean quality score of 5.4. Only 3 studies had a high quality score (>7), of which one found a lower birth weight among fasting women. Few medium quality studies found a significant negative effect on fetal growth or birth indices. The quality of articles that investigated cognitive and long-term effects was poor. The association between Ramadan fasting and health outcomes of offspring is not supported by strong evidence. To further elucidate the effects of Ramadan fasting, larger prospective and retrospective studies with novel designs are needed.

Pregnancy Fasting in Ramadan: Toward a Biocultural Framework

Pregnancy fasting poses a paradox: why would a woman restrict her diet during a period of increased nutritional need? This qualitative, cross-sectional study applied biological and cultural evolutionary theories of pregnancy diet to emic models of fasting with the aim of establishing a testable biocultural framework of pregnancy fasting. The research took place with Muslim women residing in Mysore, India. In-depth interviews were conducted with pregnant women who have experience and knowledge of fasting during during the holy month of Ramadan. Our findings indicate that pregnancy fasting is socially acquired via multiple modes of transmission and that women do not fast according to mainstream evolutionary theories of pregnancy diet, but perhaps to gain moral capital.

Associations of Pregnancy Physical Activity with Maternal Cardiometabolic Health, Neonatal Delivery Outcomes and Body Composition in a Biethnic Cohort of 7305 Mother-Child Pairs: The Born in Bradford Study

OBJECTIVE

Physical activity is advocated for a range of benefits to the uncomplicated pregnancy. We investigated associations of mid-pregnancy physical activity with maternal and neonatal health in white British and Pakistani-origin women from a deprived urban setting.

METHODS

The study was performed in 6921 pregnant women (53% Pakistani-origin) who contributed data for 7305 singleton births. At 26-28 weeks gestation, women were grouped into four activity levels (inactive/somewhat active/moderately active/active) based on their self-reported physical activity. Linear regression with robust standard errors was used to calculate adjusted mean differences in health markers between the four groups of physical activity (reference group: inactive).

RESULTS

Three-quarters (74%) of Pakistani-origin women and 39% of white British women were inactive. Trend-tests revealed that more active white British women tended to be less adipose, had lower fasting and postload glucose levels, lower triglyceride concentrations, and their babies were less adipose (smaller triceps and subscapular skinfolds) than less active white British women. Somewhat active Pakistani-origin women exhibited lower triglyceride concentrations and systolic blood pressure, higher high-density lipoprotein cholesterol levels, and their babies were less adipose (smaller mid-upper arm and abdominal circumferences; lower cord-blood leptin concentration) compared to inactive Pakistani-origin women. No associations were observed for gestational age or birth weight.

CONCLUSIONS

Physical activity performed mid-pregnancy was beneficially associated with maternal cardiometabolic health and neonatal adiposity, without influencing gestational age or birth weight. Associations were dose-dependent in white British women, and even a small amount of mid-pregnancy physical activity appeared to benefit some health markers in Pakistani-origin women.

Fasting during Ramadan Increases Risk of Very Preterm Birth among Arabic-Speaking Women

BACKGROUND

The impact of fasting on risk of preterm birth during Ramadan is unclear.

OBJECTIVES

We evaluated the association between Ramadan fasting during pregnancy and risk of preterm birth for Arab women in Canada.

METHODS

We analyzed birth certificates from 3,123,508 deliveries in Quebec, Canada, from 1981 to 2017. We identified 78,109 births of Arabic-speaking women and determined if Ramadan occurred during any trimester of pregnancy. We calculated rates of extreme (22-27 wk), very (28-31 wk), and late (32-36 wk) preterm birth and estimated RRs and 95% CIs for the association of Ramadan fasting with risk of preterm birth by pregnancy trimester, using log-binomial regression models adjusted for maternal characteristics.

RESULTS

Arabic speakers had an overall preterm birth rate of 5.53 per 100 births, but rates varied with timing of Ramadan. Among Arabic speakers, fasting during Ramadan between weeks 15-21 of the second trimester was associated with 1.33 times the risk of very preterm birth relative to no fasting (95% CI: 1.06, 1.68). Between weeks 22 and 27 of the second trimester, fasting during Ramadan was associated with 1.53 times the risk of very preterm birth (95% CI: 1.21, 1.93). Ramadan fasting was not associated with extreme or late preterm birth regardless of the trimester of pregnancy.

CONCLUSIONS

In this study of 78,109 births to Arabic-speaking women in Quebec, Ramadan fasting during the second pregnancy trimester was associated with the risk of very preterm birth. Optimal prenatal education about nutritional needs in the second trimester of pregnancy is recommended.

Perspectives and pregnancy outcomes of maternal Ramadan fasting in the second trimester of pregnancy

Background

There are controversies over the effects of Ramadan fasting on pregnancy outcomes, and women’s perspectives of fasting are diverse. This study aimed to assess the perspectives and pregnancy outcomes of maternal Ramadan fasting in the second trimester of pregnancy.

Methods

A case-control study was conducted at Hawler Maternity Teaching Hospital of Erbil, Iraq from October 2017 to January 2018. Out of 301 participating women, 155 fasted during the second trimester of their current pregnancy, while the remaining 146 did not. Mothers were asked concerning their fasting behaviors and perception of fasting during pregnancy. The main outcomes of this study were gestational diabetes, preterm labour, preeclampsia, low birth weight, Apgar score, height, weight, and head circumference of the newborn.

Results

About 80% of the women in the fasting group fasted for 21–29 days during Ramadan, out of whom 38.7% completed fasting for the entire Ramadan period. The results revealed that the decision to fast during pregnancy was negatively associated with the mother’s educational level and occupation. Weight gain during pregnancy in the fasting women was approximately 0.4 kg less than those who did not fast. The incidence of gestational diabetes was 2.6% in the fasting women, while it was 8.3% in the non-fasting mothers (P = 0.02). Regression analysis showed that women who did not fast during the second trimester of pregnancy were 1.51 times more likely to develop gestational diabetes [odd ratio (OR) 1.51; 95% confidence intervals (CI) 0.06, 0.74, P = 0.01]. It was also found that among the women in the fasting categories, those who fasted for 21–29 days during pregnancy had a lower risk of gestational diabetes compared to the other groups. More than half of the mothers in the fasting group (60%) perceived that fasting during pregnancy was compulsory for healthy and non-healthy women, comparing with those who did not fast.

Conclusion

It was found that fasting during the second trimester of the pregnancy decreased the risk of gestational diabetes and excessive weight gain during pregnancy. Most of Iraqi women did not fully recognize their right to be exempted from fasting during pregnancy by the Islamic law.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2275-x) contains supplementary material, which is available to authorized users.

The effect of Ramadan fasting during pregnancy on perinatal outcomes: a systematic review and meta-analysis

Background

Although exempt, many pregnant Muslim women partake in the daily fast during daylight hours during the month of Ramadan. In other contexts an impoverished diet during pregnancy impacts on birth weight. The aim of this systematic review was to determine whether Ramadan fasting by pregnant women affects perinatal outcomes. Primary outcomes investigated were perinatal mortality, preterm birth and small for gestational age (SGA) infants. Secondary outcomes investigated were stillbirth, neonatal death, maternal death, hypertensive disorders of pregnancy, gestational diabetes, congenital abnormalities, serious neonatal morbidity, birth weight, preterm birth and placental weight.

Methods

Systematic review and meta-analysis of observational studies and randomised controlled trials was conducted in EMBASE, MEDLINE, CINAHL, Web of Science, Google Scholar, the Health Management Information Consortium and Applied Social Sciences Index and Abstracts. Studies from any year were eligible. Studies reporting predefined perinatal outcomes in pregnancies exposed to Ramadan fasting were included. Cohort studies with no comparator group or that considered fasting outside pregnancy were excluded, as were studies assuming fasting practice based solely upon family name. Quality of included studies was assessed using the ROBINS-I tool for assessing risk of bias in non-randomised studies. Analyses were performed in STATA.

Results

From 375 records, 22 studies of 31,374 pregnancies were included, of which 18,920 pregnancies were exposed to Ramadan fasting. Birth weight was reported in 21 studies and was not affected by maternal fasting (standardised mean difference [SMD] 0.03, 95% CI 0.00 to 0.05). Placental weight was significantly lower in fasting mothers (SMD -0.94, 95% CI -0.97 to  -0.90), although this observation was dominated by a single large study. No data were presented for perinatal mortality. Ramadan fasting had no effect on preterm delivery (odds ratio 0.99, 95% CI 0.72 to 1.37) based on 5600 pregnancies (1193 exposed to Ramadan fasting).

Conclusions

Ramadan fasting does not adversely affect birth weight although there is insufficient evidence regarding potential effects on other perinatal outcomes. Further studies are needed to accurately determine whether Ramadan fasting is associated with adverse maternal or neonatal outcome.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-2048-y) contains supplementary material, which is available to authorized users.

Ramadan Observance during Pregnancy in Germany: a Challenge for Prenatal Care

INTRODUCTION

Fasting during Ramadan while pregnant has been shown to have long-term negative effects on the offspring's physical and cognitive health. Even though most Muslims do not believe pregnant women are obligated to fast during Ramadan, fasting rates of up to 87% have been reported for pregnant women. No data exists to date about Ramadan adherence and behavior in Germany.

METHODS

The Mainz Study of Ramadan and Pregnancy surveyed pregnant Muslims and new Muslim mothers in Mainz between October 2016 and January 2017 and collected information on Ramadan adherence and behavior. We also collected data on personal characteristics and opinions, to identify determinants of fasting using statistical analysis.

RESULTS

We found that 43% of pregnant Muslim women fasted at least one day during Ramadan 2016. Women who fasted were significantly younger and less educated. There was no significant difference in terms of country of origin between those women who fasted and those who did not. Only 49% of women who fasted and 38% of women who did not fast discussed their Ramadan behavior with their doctor. Less than 2% of women reported being proactively approached by their doctor.

CONCLUSION

To ensure that pregnant Muslim women living in Germany can make their fasting decision based on objective information, it is necessary to raise awareness about Ramadan fasting during pregnancy among medical professionals in Germany.

Ramadan during pregnancy and birth weight of newborns

Previous studies suggest that Ramadan exposure during pregnancy might affect the health of women and their babies, particularly through the effect of fasting. This study aimed to evaluate the association between Ramadan exposure and fasting during pregnancy on the birth weight of newborns. This study concerned 1351 pregnant women from a prospective cohort in Jakarta, Indonesia. Ramadan exposure was based on the actual overlap between Ramadan and pregnancy. Women's fasting behaviour was recorded among 139 women who came for antenatal care between 10 July 2013 and 7 August 2013, and those who had fasted for at least 1 d (n 110) were classified as exposed to Ramadan fasting. Furthermore, a 24 h dietary recall was performed and repeated 1 month later. Birth weight of newborns who were exposed to Ramadan during pregnancy did not significantly differ from those who were not, both in the total and trimester-specific analysis. Maternal fasting did not seem to affect the birth weight of newborns (-72 (95 % CI -258, 114) g; P = 0·44), although there was a non-significant trend towards lower birth weight with fasting in the second and third trimester. Women who fasted had significantly lower total energy, macronutrient and water intake as compared with women who did not. Women's intake was also lower during Ramadan (regardless of their fasting behaviour) as compared with 1 month later. Lifestyle changes that occur with Ramadan and fasting during pregnancy are associated with lower reported energy intake. We cannot conclude on the effect of fasting on birth weight due to low statistical power.

Nursing Care of Pregnant Muslim Women During Ramadan

There are approximately 3.3 million people of the Muslim faith living in the United States. This article explores how Muslim women observe their religious beliefs during pregnancy and discusses implications for nursing care of pregnant Muslim women during Ramadan. Although pregnant Muslim women can be exempt from fasting, many still choose to fast during Ramadan. Factors that influence a woman's decision to fast include gravity and parity, maternal education, maternal age, body mass index, comprehension of Islamic Law, and gestational trimester. Nurses can tailor their care of pregnant Muslim women to include episodes of fasting and help them make informed decisions regarding fasting during Ramadan.