Episode 168 Ramadan, it's ok to ask

Have you ever experienced a moment of cultural awakening, realizing that there's so much more to learn about the traditions of those around us? That's exactly what happened to me, Florence, after reading an enlightening tweet from the outstanding obstetrician Nisha Knot, which set me on a path to discover more about Ramadan and its effects on pregnancy. Join me on the OBSpod as I navigate my own journey of understanding, driven by the realization that many of the Muslim women we support in healthcare are observing this pillar of their faith. This episode is a heartfelt quest for knowledge, as I tackle the complexities of fasting during pregnancy without the guiding voice of an expert guest, but with the earnest desire to learn more and share that knowledge with you.

As we ponder the impact of fasting on expecting mothers and how this practice varies across the globe due to differences in daylight hours, I turn to a pivotal article that serves as an evidence-based guideline for obstetricians. This episode isn't just about sharing what I've learned; it's an invitation to engage in a more inclusive and informed maternity care conversation. I hope that by openly discussing my own educational gaps and curiosities, we can all feel empowered to ask questions and seek answers together. So whether you're a healthcare professional, a pregnant woman observing Ramadan, or simply someone intrigued by the intersection of culture and care, this episode is for you. Let's grow our understanding and become better allies to the diverse communities we serve.

Want to know more?
https://www.ajog.org/article/S0002-9378(23)00169-2/abstract
https://maternityandmidwifery.co.uk/fasting-in-ramadan-during-pregnancy-and-breastfeeding-a-personal-journey/
https://youtu.be/E2AceO2j2oc

Thank you all for listening, My name is Florence Wilcock I am an NHS doctor working as an obstetrician, specialising in the care of both mother and baby during pregnancy and birth. If you have enjoyed my podcast please do continue to subscribe, rate, review and recommend my podcast on your podcast provider.
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Transcript

Florence: 0:00

Hello, my name's Florence. Welcome to the OBSpod. I'm an NHS obstetrician hoping to share some thoughts and experiences about my working life. Perhaps you enjoy Call the Midwife. Maybe birth fascinates you, or you're simply curious about what exactly an obstetrician is. You might be pregnant and preparing for birth. Perhaps you work in maternity and want to know what makes your obstetric colleagues tick, or you want some fresh ideas and inspiration. Whichever of these is the case and, for that matter, anyone else that's interested, the OBS pod is for you.

Florence: 0:48

Episode 168, ramadan. It's okay to ask. I am going to start by telling you I am not an expert on Ramadan. In fact, I know very little about it, and this is what prompted this episode. It all started when I saw a tweet from Nisha Khot, a fantastic obstetrician who used to work with me but who is now one of the vice presidents of the Australian and New Zealand College of Obstetrics and Gynaecology. She lives and practices in Australia. She was highlighting an article in the American Journal of Obstetrics and Gynaecology about the effects of Ramadan on pregnancy. This sparked something in my mind. It made me think back to the report which I helped contribute to in a small way, by Baroness Gohir Invisible Muslim women's experience of maternity care Invisible. It got me thinking.

Florence: 2:09

In the UK, around six and a half percent of the population are Muslim and whilst I don't work in an inner London, trust in London. I imagine the proportion is much higher. Trust in London I imagine the proportion is much higher. Therefore, year in, year out, I see Muslim women during Ramadan. I must do, but if I think about the conversations I've had with those women, it's rare that it crops up in the conversation. So I had one of those moments where you suddenly realise your level of ignorance and I put out a message on my Instagram and Twitter because I thought I can't possibly do an episode about Ramadan because I don't know enough about it. I need a guest because I don't know enough about it. I need a guest. I need a Muslim colleague or Muslim parent to come on and tell me a bit about it.

Florence: 3:13

But Ramadan is a month and it has a time frame and whilst I did get some excellent resources back, which I'm going to mention in a moment from ally colleagues, I didn't get anything back from any Muslim women themselves. So I had a choice. The end of Ramadan is in a week and a bit's time. Do I park it, leave it for another year, because it's not appropriate for me, a non-Muslim, to tell people about Ramadan. Or do I take the approach of Terri Gavin Jones, a wonderful midwife who I talked to on episode 136, all about cultural curiosity? Do I take Terri's approach and say it's okay to ask? So I thought I'd bite the bullet, I'd do an episode on Ramadan because otherwise this year will have been missed and it's okay for me to ask and it's okay for me to say I'm ignorant, and I very much hope that someone listening to this somewhere it will spark some thoughts and maybe next year, when Ramadan comes around, we could record an episode together. So, in my little quest to explore Ramadan, what have I learnt?

Florence: 4:49

Well, I'm going to start with that article and I will put a link in the show notes, but you may need an institutional login to be able to access the whole thing. So the article is called Ramadan, fasting and Pregnancy an evidence-based guideline for the obstetrician. The article starts by telling us what Ramadan is. Telling us what Ramadan is. It consists of refraining from smoking, food, including chewing gum, and medication, and drink, including water, and refraining from sexual activity from dawn until sunset for a month. At sunset, Muslims are encouraged to break their fast iftar with electrolyte rich and nutrient rich food and eat a healthy early breakfast, suhoor, before the next dawn. I knew already that Ramadan was a lunar month and therefore moves around the year, and in the northern hemisphere this is relevant because it means the hours of fasting can be significantly longer. If you live near the tropics, from dawn until dusk is likely to be roughly a 12-hour period, whereas for those of us in the northern or southern hemisphere, depending on the time of year, muslims may be fasting for up to 16 or more hours. Because Ramadan lasts for a month and obviously pregnancy is nine months, it is very likely that Ramadan will fall at some point during a woman's pregnancy and therefore many Muslim women will have a dilemma about what they do during Ramadan.

Florence: 6:42

Before I go any further, I thought I needed to explore what's the point of Ramadan, and that sounds a bit rude, but I understand fasting, but fasting for a month in this way. I didn't really appreciate and understand what that might mean or why you might want to do. That. Links, in particular, an account by a wonderful midwife, fatima Mohameid, about the dilemma she had personally in whether to fast in pregnancy or not. What she outlines in her account is that it wasn't just about the fasting. It was about the spirituality, the sense of community and re-energising willpower that this month of Ramadan brought, and I think that's something I hadn't really understood, that it's not a suggestion that one must fast and that's all there is to it. It's a much broader cultural and spiritual event in which one's involved. The whole community is behaving in this way together. Whole community is behaving in this way together, and she talked about the difficulty of fasting contrasted with the difficulty of suddenly not being involved in that strong sense of community and spirituality that was going on around her. She also talks about the fact that she'd fasted every Ramadan from the age of 11. And I think that's something we need to consider that this is something women have done every year for a very large part of their life, and suddenly being faced with the dilemma about what to do and whether or not it's safe to fast is a massive challenge. Dr Jenny Hall also sent me a link to one of her Matt Flick hour talks, also given by Fatima, and through that I learned that fasting is one of the five pillars of Islam. I know I sound terribly ignorant, but I hadn't understood that either. So the fast of Ramadan is very central to the five pillars of Islam that make one a Muslim. This has made me realise all these missed opportunities.

Florence: 9:47

I've had to talk to people about Ramadan, and I'm not just talking about parents and women I see in my clinic, but my colleagues. I have a number of Muslim colleagues every year and I do know they're fasting, usually because I'm at pains to try and make sure that the doctors working with me are having breaks, or people around me midwives and support workers are getting drinks, and I will offer to get people coffee and I will check whether people have had some sort of lunch break and eaten, and sometimes I get the response no, I don't want coffee, I'm fasting, or I don't need to go for lunch, I'm fasting, and I accept that and move on Instead of which. Maybe I should be a bit more curious. Maybe I should be asking them a bit more about that. Maybe I could say tell me a bit about that, educate me. But I don't, and I think part of that is I'm worried about being nosy, I'm worried about being obtrusive and worried about being obtrusive, or I think I should know. Perhaps we don't talk to people enough about their different cultures and ask questions. Just this weekend I had a wonderful conversation on the bus with a group of guys who were getting ready for IFTA, and the only reason we struck up a conversation is we had our dog with us and our dog was sniffing their various bags of shopping on the bus and it turned out there was fish in the bags for Iftar. They were going off to cook and celebrate the end of that day's fast. So, having given you a little bit of an overview of what is Ramadan and hopefully some personal perspectives from the lovely Fatima and the resources I've been signposted to, what is the impact on pregnancy? And for that I'm going to return to this article.

Florence: 12:21

In the American Journal of Obstetrics and Gynaecology they did a literature review looking at the studies on fasting during Ramadan and pregnancy to look at maternal and fetal outcomes. Interestingly, they found little to no clinical significant effect of fasting on neonatal birth weight or preterm delivery. They commented that fasting during Ramadan had mainly been associated with signs and symptoms of maternal fatigue and dehydration, with a minimal decrease in weight gain, and there was conflicting data about the association of gestational diabetes and insufficient data on maternal hypertension, of gestational diabetes and insufficient data on maternal hypertension. They say that literature on the long-term effects of fasting on offspring suggests possible adverse effects but that really more data is required. And it concludes that in counselling patients, obstetricians should be prepared to discuss the nuances in the data and demonstrate cultural and religious awareness and sensitivity to foster a trusting relationship between women and their providers.

Florence: 13:39

And then in the paper they include a framework just to kind of suggest how you might do that, just to kind of suggest how you might do that. It suggests putting up posters in the antenatal clinic and it describes being aware when Ramadan falls, asking women if they plan to fast, using open-end, respectful questions such as what are your thoughts about fasting during Ramadan? Do you have any concerns? It kind of says the obvious things like being non-judgmental, understand the importance of fasting during Ramadan. It talks about shared decision making and individualised recommendations, so providing some medical recommendations based on clinical experience and this paper on the actual outcomes. And it talks about talking to women about increased symptoms of maternal fatigue and dehydration and therefore is reasonable for providers to recommend against prolonged fasting while pregnant but not to give what they call blanket prohibitions against fasting, given that there isn't strong evidence against fasting, given that there isn't strong evidence. Then it talks about supporting pregnant women who choose to fast and how they might minimise the impact thinking about healthy exercise, sleep, nutritious bedtime, snacks and breakfast and how to make sure that in the hours they are eating, they're getting a good, balanced diet. They also talk about discussing with women what signs and symptoms might mean that breaking the fast is necessary and possibly offering some additional antenatal visits to increase monitoring of the woman and her baby. And then it also talks about supporting pregnant women who are observing Ramadan but not fasting. So it's a really helpful box of thought-provoking stuff and I will put a picture of it on my Instagram because I think, even if you do nothing else, then that could be really helpful in opening up conversation.

Florence: 16:26

What's my zesty bit? I think for me, the take-home message is very much not being afraid to open up a conversation about Ramadan when I see Muslim women and I'm going to try and put that into effect this year very much with the awareness of it's okay to ask and also maybe be a bit more curious with my Muslim colleagues. If you're pregnant and listening to this and you're Muslim, then I think the same is true don't be afraid to talk to your midwife or obstetrician about fasting and Ramadan and what you are or aren't doing, but, most importantly, know that it doesn't seem like this is having a negative impact on the growth and development of your baby and a healthy pregnancy for you the growth and development of your baby and a healthy pregnancy for you. But you may experience some symptoms of being particularly tired or dehydrated. So bear that in mind. And my final zesty bit is I would absolutely love it if someone listening to this who is Muslim, who is or who has experienced Ramadan in pregnancy got in touch and would be willing to come on the podcast and talk to me about it, ready for next Ramadan.

Florence: 18:04

I very much hope you found this episode of the OBS pod interesting. If you have, it'd be fantastic if you could subscribe, rate and review on whatever platform you find your podcasts. As well as recommending the OBS pod to anyone you think might find it interesting, there's also tons of episodes to explore in my back catalogue from clinical topics, my career and journey as an obstetrician and life in the NHS more generally. I'd like to assure women I care for that I take confidentiality very seriously and take great care not to use any patient identifiable information unless I have expressly asked the permission of the person involved on that rare occasion when it's been absolutely necessary. If you found this episode interesting and want to explore the subject a little more deeply, don't forget to take a look at the programme notes, where I've attached some links.

Florence: 19:17

If you want to get in touch to suggest topics for future episodes, you can find me at TheObsPod, on Twitter and Instagram. Find me at TheObsPod on Twitter and Instagram and you can email me theobspod at gmailcom. Finally, it's very important to me to keep TheObsPod free and accessible to as many people as possible, but it does cost me a very small amount to keep it going and keep it live on the internet. So if you've enjoyed my episodes and, by chance, you do have a tiny bit to spare, you can now contribute to keep the podcast going and keep it free via my link to buy me a coffee. Don't feel under any obligation, but if you'd like to contribute, you now can. Thank you for listening.