The effect of maternal fasting during Ramadan on preterm delivery: a prospective cohort study

Ramadan during pregnancy and offspring health outcomes over the life course: a systematic review and meta-analysis

BACKGROUND

Intermittent fasting, such as during Ramadan, is prevalent among pregnant women. However, the association between Ramadan during pregnancy and offspring health along the life course has not been fully established.

OBJECTIVE AND RATIONALE

Fetal programming research indicates that prenatal exposures, particularly during early pregnancy, can cause long-term structural and physiological changes that adversely affect offspring health. Our objective was to systematically identify and assess the evidence regarding Ramadan during pregnancy.

SEARCH METHODS

A total of 31 studies were sourced from PubMed, EMBASE, Web of Science, and EconLit. Included studies evaluated outcomes in individuals with prenatal Ramadan exposure, compared to unexposed Muslim controls. Main outcomes were birth weight, gestational length, and sex ratio in newborns; height, mortality, and cognition in children; and disabilities, chronic diseases, and human capital accumulation in adults. Each study was evaluated for risk of bias. The overall quality of evidence was appraised using the GRADE system. Random-effects meta-analyses were conducted for outcomes analyzed in at least three primary studies.

OUTCOMES

The initial search identified 2933 articles, 1208 duplicates were deleted. There were 31 publications fulfilled the eligibility criteria for the qualitative synthesis; 22 studies were included in meta-analyses. The overall quality of the evidence was low to moderate and differed by study design and outcome. Among newborns, prenatal Ramadan exposure was not associated with birth weight (mean difference (MD) -3 g (95% CI -18 to 11; I2 = 70%) or the likelihood of prematurity (percentage point difference (PPD) 0.19 (95% CI -0.11 to 0.49; I2 = 0%)). The probability that the newborn is male was reduced (PPD -0.14 (95% CI -0.28 to -0.00; I2 = 0%)). This potentially reflects sex-specific mortality rates resulting from adverse in utero circumstances. In childhood, the exposed performed slightly poorer on cognitive tests (MD -3.10% of a standard deviation (95% CI -4.61 to -1.58; I2 = 51%)). Height among the exposed was reduced, and this pattern was already visible at ages below 5 years (height-for-age z-score MD -0.03 (95% CI -0.06 to -0.00; I2 = 76%)). A qualitative literature synthesis revealed that childhood mortality rates were increased in low-income contexts. In adulthood, the prenatally exposed had an increased likelihood of hearing disabilities (odds ratio 1.26 (95% CI 1.09 to 1.45; I2 = 32%)), while sight was not affected. Other impaired outcomes included chronic diseases or their symptoms, and indicators of human capital accumulation such as home ownership (qualitative literature synthesis). The first trimester emerged as a sensitive period for long-term impacts.

WIDER IMPLICATIONS

Despite the need for more high-quality studies to improve the certainty of the evidence, the synthesis of existing research demonstrates that Ramadan during pregnancy is associated with adverse offspring health effects in childhood and especially adulthood, despite an absence of observable effects at birth. Not all health effects may apply to all Muslim communities, which are diverse in backgrounds and behaviors. Notably, moderating factors like daytime activity levels and dietary habits outside fasting hours have hardly been considered. It is imperative for future research to address these aspects.

REGISTRATION NUMBER

PROSPERO (CRD42022325770).

Adverse effects of gestational exposure to hexafluoropropylene oxide trimer acid (HFPO-TA) homologs on maternal, fetal, and placental health in mice

In an effort to identify and develop potential alternatives for perfluorooctanoic acid (PFOA), PFDMO2HpA and PFDMO2OA have been engineered by reducing the -CF2 content in the molecular structure of hexafluoropropylene oxide trimer acid (HFPO-TA). Yet, despite their subsequent presence in environmental samples, there is a paucity of information regarding their toxicity, particularly on pregnancy. Here, pregnant CD-1 mice were exposed to PFDMO2HpA (0, 0.04, 0.16, 0.63, 2.5, or 10 mg/kg/day) or PFDMO2OA (0, 0.01, 0.04, 0.16, 0.63, or 2.5 mg/kg/day) via oral gavage from gestational days 2 (GD2) to 12 or 18 to evaluate the detrimental effects on dams and embryo-placenta units. Both two chemicals can transfer across the placenta, with a higher transfer ratio in late-pregnancy (GD18) than in mid-pregnancy (GD12), and PFDMO2OA being transferred at a higher rate than PFDMO2HpA. PFDMO2HpA/PFDMO2OA exposure caused maternal hepatotoxicity and fetal hepatomegaly, showing the lowest no-observed-adverse-effect level among all observed endpoints, which were used for calculating their reference dose (13.33 ng/kg/day). In the 2.5 and 10 mg/kg/day PFDMO2HpA groups as well as 2.5 mg/kg/day PFDMO2OA group at GD18, besides the abnormally high abortion rates exceeding 5 %, survival fetal weight was notably reduced (2.33 %, 6.44 %, and 5.59 % decrease relative to corresponding controls, respectively). Concurrently, placentas exhibited significant enlargement following PFDMO2HpA or PFDMO2OA exposure at doses of 0.63 mg/kg/day or higher, resulting in diminished placental efficiency. The deleterious effects of two chemicals on dams, fetuses, and placentas were stronger than that of PFOA or HFPO-DA, suggesting that neither PFDMO2HpA nor PFDMO2OA is suitable PFOA alternative. Bioinformatics analyses revealed significant alterations in the expression of genes involved in inflammation and immunity in the placenta upon exposure to 10 mg/kg/day PFDMO2HpA and 2.5 mg/kg/day PFDMO2OA at GD18, potentially elucidating mechanism behind the observed decrease in placental efficiency and increase in abortion rates after exposure.

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.

Global Research Trends of Health-Related Publications on Ramadan Fasting from 1999 to 2021: A Bibliometric Analysis

Ramadan fasting is one of the five pillars of Islam. The current study aims to examine, analyze, and identify trends of health-related publications on Ramadan fasting. In total, 1468 documents retrieved from Scopus were analyzed. The mean number of authors per document was 3.7, with an average of 13.3 citations per document. The UK ranked first (12.3%, n = 181) regarding the number of documents, followed by Iran (10.4%, n = 153) and then Saudi Arabia (9.8%, n = 144). The most active journal was "Diabetes Research and Clinical Practice" (4.9%, n = 72). Publications related to diabetes and fasting constituted around 29.7% (n = 436) of the literature. The research volume on Ramadan fasting has been noticeably growing. More reliable research is required to aid healthcare professionals in providing patient-specific care.

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.

Ramadan Fasting: Perception and maternal outcomes during Pregnancy

Objectives:

To see perception and knowledge of women about Ramadan fasting and maternal effects of fasting.

Methods:

The study design was prospective, case-controlled. This study was conducted at Holy Family Hospital from 1^st May 2020 to July 2020. Pregnant women with spontaneous conception and singleton pregnancies, who fasted for seven or more days, were cases, and those who did not fast were taken as controls. Questionnaire was filled regarding perception of women about maternal fasting. Primary maternal outcomes included preterm delivery, pregnancy induced hypertension, and gestational diabetes mellitus. The analysis was conducted using Statistical Package for Social Sciences version 16.0.

Results:

A total of 215 women were included in the study, 123 women fasted, and 92 women did not fast. Only 2.8% of women knew that fasting is forbidden in pregnancy. Sixty five percent of women reported weakness as the main reason for not fasting. The rate of gestational diabetes, pregnancy induced hypertension and preterm delivery was higher among women who fasted (17% vs 14%, 7% vs 2%, 9% vs 9%) respectively, compared to non-fasting women, but were not found statistically significant. There was no difference in anthropometric measurements of newborn, among both groups.

Conclusion:

Ramadan fasting does not affect maternal outcomes during pregnancy.

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.

Maternal and Perinatal outcome after Ramadan Fasting

Objective:

To determine maternal and perinatal outcome after Ramadan fasting during pregnancy

Methods:

This cross sectional study was conducted at The Department of Obstetrics and Gynaecology, Nishtar Hospital, Multan from May to October 2019. A total of 226 women attending labour room, aged 18–35 years, having gestational amenorrhoea 15 – 40 weeks of gestation were included. Women who fasted for more than 15 days were compared with those who did not fast or fasted for less than 15 days in the month of Ramadan. Demographical profile along with maternal and perinatal outcomes were compared between the study groups considering p value less than 0.05 as significant.

Results:

Out of 226 women, 58 (25.7%) fulfilled the criteria to be included in the fasting group while remaining 168 (74.3%) were slotted in the non-fasting group. There was no difference (p value > 0.05) in between the both group with respect to demographical characteristics except significantly less women were employed in the fasting group (p value=0.0246). No statistical difference was found in terms of maternal or perinatal outcomes between both the study groups.

Conclusion:

Fasting women were not found to have poor maternal and fetal outcomes when compared to non-fasting women.

Gestational Weight Gain: Update on Outcomes and Interventions

PURPOSE OF REVIEW

Gestational weight gain is a modifiable risk factor for adverse perinatal outcomes. After the Institute of Medicine (IOM) released updated recommendations for gestational weight gain in 2009, a multitude of studies were released examining the recommendations, particularly for women with obesity. As the obesity epidemic continues, many physicians are interested in minimizing gestational weight gain for all women. Our aim was to review the evidence for the association of gestational weight gain and perinatal outcomes, particularly for weight gain outside the IOM guidelines.

RECENT FINDINGS

Gestational weight gain is associated with several adverse perinatal outcomes including fetal growth, preterm delivery, cesarean delivery, gestational diabetes, hypertensive disorders of pregnancy, and infant mortality as well as with long-term offspring metabolic health outcomes. Multiple randomized controlled trials have been conducted evaluating the efficacy of lifestyle intervention on gestational weight gain, and while lifestyle interventions may alter gestational weight gain, they have not been associated with improvement in perinatal outcomes. Weight loss during pregnancy is associated with decreased risks of macrosomia and cesarean delivery; however, given an association with low birth weight, it is not currently recommended. Excessive gestational weight gain is known to be associated with multiple adverse fetal and maternal outcomes. Lifestyle interventions during pregnancy may be helpful in decreasing excessive weight gain, but have not shown to be beneficial for most adverse pregnancy outcomes. More research is needed before making recommendations for weight loss in women with obesity during pregnancy.

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.

Physicians' attitudes and views regarding religious fasting during pregnancy and review of the literature

Many patients worldwide seek medical advice regarding safety of fasting during pregnancy. This issue lacks high quality evidence, which makes giving medical advice challenging. To aid decision making on this subject we performed an internet mediated survey to determine the expert opinion on this issue. The survey was answered by one hundred and eight obstetricians and gynecologists (OB/GYN). The questions were aimed at the content of the medical advice given to pregnant patients on Ramadan (for Muslim patients) and Yom Kippur (for Jewish patients) fasts. For both fasts, most physicians recommended against fasting on the second or third trimester, while fasting on the first trimester was controversial. Differences were found between medical advices provided by physicians according to their demographical characteristics. Regarding Ramadan fast, senior specialists were more lenient about fasting than younger specialists (62% and 35%, respectively, p = 0.01). As to Yom Kippur fast, religious and traditional physicians were more likely to permit fasting compared to their secular colleagues (53% and 25%, respectively, p = 0.01). Additionally, a comprehensive literature review was conducted revealing possible adverse maternal and fetal outcomes of fasting; however the risk for long term clinical complications is yet to be defined.

Pre-Ramadan health seeking behavior, fasting trends, eating pattern and sleep cycle in pregnant women at a tertiary care institution of Pakistan

Objective:

To observe the pre-Ramadan health seeking behavior, fasting trends, eating pattern and, sleep cycle in pregnant women.

Methods:

It is a cross-sectional observational study, from July to September 2017, conducted at Tertiary Care Hospital in Karachi. The tool used for data collection was interviewer based closed ended questionnaire, 279 pregnant women who fasted during Ramadan were included in the study.

Results:

One to ten days of fasting was observed by 85.7% (198) of women. About 72.4% (202) never consulted any doctor for pre-Ramadan advice regarding fasting in pregnancy. Pregnant women 81.7% (228) believed that fasting would not cause any harm to their unborn child, while 42.7% (119) of family members feared about the health of mother and unborn child. Seventy four percent (208) of respondents had a reduced sleep cycle of about 3-4 hours. The food items consumed at Sehri and Iftar were rich in carbohydrates and fats.

Conclusions:

Pre-Ramadan medical consultation regarding safety of fasting during pregnancy should be structured and customized for women and their families. Gaps in knowledge identified in this study may help healthcare professionals to address these issues.

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.

The effect of prenatal exposure to Ramadan on children's height

We examine the effect of prenatal exposure to Ramadan on children's height by sex, age, region, and the degree of religiosity. Since Ramadan rotates on solar calendars, we pool demographic and health survey data from numerous developing countries to increase the number of birth years and fairly control for potential seasonal effects. Our results suggest that Ramadan-induced nutritional stress during early- and mid-gestation may negatively affect the height of 3 and 4 years old Muslim male children. The effect tends to be stronger in West Africa and Central Asia. It also tends to be stronger in more religious countries. We do not detect consistent negative effects on height in female children.

Ethiopian Orthodox Fasting and Lactating Mothers: Longitudinal Study on Dietary Pattern and Nutritional Status in Rural Tigray, Ethiopia

About half of Ethiopians belong to the Orthodox Tewahedo religion. Annually, more than 200 days are dedicated to religious fasting, which includes abstaining from all types of food, animal source foods, and water. However, the association of fasting with undernutrition remains unknown in Ethiopia. Therefore, dietary pattern and nutritional status of lactating women during lent fasting and non-fasting periods were studied, and predictor variables for maternal underweight were identified. To achieve this, lactating mothers in lent fasting (N = 572) and non-fasting (N = 522) periods participated from rural Tigray, Northern Ethiopia. Average minimum diet diversity (MDD-W) was computed from two 24-h recalls, and nutritional status was assessed using body mass index (BMI). Binary logistic regression was used to identify potential predictors of maternal underweight. Wilcoxon signed-rank (WSRT) and McNemar's tests were used for comparison of the two periods. The prevalence of underweight in fasting mothers was 50.6%. In the multivariate logistic regression model, younger age, sickness in the last four weeks preceding the survey, fasting during pregnancy, lactation periods, grandfathers' as household decision makers, previous aid experience, non-improved water source, and not owning chicken were positively associated with maternal underweight. In WSRT, there was no significant (p > 0.05) difference on maternal body weight and BMI between periods. The average number of meals, diet diversity, and animal source foods (ASFs), consumption scores were significantly increased in non-fasting compared to fasting periods in both fasting and non-fasting mothers (p < 0.001, p < 0.05, and p < 0.001, respectively). Consumption of dark green leafy vegetables was higher in the fasting period (11%) than non-fasting (3.6%), in the study population. As a conclusion, Ethiopian Orthodox fasting negatively affected maternal nutritional status and dietary pattern in rural Tigray, Northern Ethiopia. To reduce maternal malnutrition in Ethiopia, existing multi-sectoral nutrition intervention strategies, should include religious institutions in a sustainable manner.

Perinatal outcome among fasting and non fasting mothers during the month of Ramadan

Objective:

To compare the perinatal outcome among fasting and non fasting pregnant mothers.

Methods:

A total of 180 women, who came for delivery in the labor suite were included, after verbal informed consent. These women were divided in two groups fasting (n=100), and non-fasting (n=80).

Results:

The mean age of the mothers was 27.16±4.27 years in the fasting group and 27.36±4.92 years in non-fasting group. The average BMI of mothers was 25.31±3.26 kg/m²in fasting group while 25.64±3.58 kg/m²in non-fasting group. Perinatal outcomes, the birth weight, head circumference and mid arm circumference were almost similar between the two groups. Weight of placenta was 537.80±80.01g in fasting group while 540.50±84.29 g in non-fasting group and height of baby was 45.79±3.07 cm in fasting group while 46.61±2.92 cm in non-fasting group. In fasting group, placenta weight was 531.5±92.80 g in boys while 544.8±62.79 g in girls and ratio of placental to birth weight was 18.8±2.28 in boys while 19.4±2.70 in girls.

Conclusion:

Maternal fasting affects placental weight and length of baby, with effect more pronounced in male babies.

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.

A new model for fetal programming: maternal Ramadan-type fasting programs nephrogenesis

The effect of maternal Ramadan-type fasting (RTF) on the outcome of pregnancy, kidney development and nephron number in male rat offspring was investigated in current study. Pregnant rats were given food and water ad libitum during pregnancy (control) or restricted for 16 h per day (RTF). Kidney structure was examined during fetal life, at birth, and in early and late adulthood. Maternal body weight, food intake, relative food intake and plasma glucose levels were significantly lower (P<0.001) in the RTF group. Litter and pup weights also were significantly lower (P<0.05) in the RTF group at birth, with no difference in the litter size. The RTF group had a longer gestation, delayed nephrogenesis with less well-differentiated glomeruli, more connective tissue, fewer medullary rays, an increase in the nephrogenic zone/cortical zone ratio, and significant increase (P<0.001) in kidney apoptosis at birth. On the other hand, maternal fasting reduced nephron number (by ~31%) with unchanged kidney and total glomerular volumes. Mean glomerular volume was significantly higher in RTF offspring. Assessment of renal structure revealed mild glomerulosclerosis with enlarged lobulated glomeruli in the renal cortex and high interstitial fibrosis in the medulla of RTF kidneys. Taken together, gestational fasting delays nephrogenesis and reduces nephron number in the kidneys of the offspring, that could be partially owing to increased apoptosis.

Predictors of Ramadan fasting during pregnancy

Although the health effects of Ramadan fasting during pregnancy are still unclear, it is important to identify the predictors and motivational factors involved in women’s decision to observe the fast. We investigated these factors in a cross sectional study of 187 pregnant Muslim women who attended antenatal care visits in the Budi Kemuliaan Hospital, Jakarta, Indonesia. The odds of adherence to fasting were reduced by 4% for every week increase in gestational age during Ramadan [odds ratio (OR) 0.96; 95% confidence interval (CI) 0.92, 1.00; p = 0.06] and increased by 10% for every one unit increase of women’s prepregnancy body mass index (BMI) (OR 1.10; 95% CI 0.99, 1.23; p = 0.08). Nonparticipation was associated with opposition from husbands (OR 0.34; 95% CI 0.14, 0.82; p = 0.02) and with women’s fear of possible adverse effects of fasting on their own or the baby’s health (OR 0.47; 95% CI 0.22, 1.01; p = 0.05 and OR 0.43; 95% CI 0.21, 0.89; p = 0.02, respectively), although they were attenuated in multivariable analysis. Neither age, income, education, employment, parity, experience of morning sickness, nor fasting during pregnancy outside of Ramadan determined fasting during pregnancy. Linear regression analysis within women who fasted showed that the number of days fasted were inversely associated with women’s gestational age, fear of possible adverse effects of fasting on their own or the fetal health, and with opposition from husbands. In conclusion, earlier gestational age during Ramadan, husband’s opinion and possibly higher prepregnancy BMI, influence women’s adherence to Ramadan fasting during pregnancy. Fear of adverse health effects of Ramadan fasting is common in both fasting and non-fasting pregnant women.

Ketoacidosis in diabetic pregnancy

Diabetic ketoacidosis (DKA) is a serious medical and obstetrical emergency previously considered typical of type 1 diabetes but now reported also in type 2 and GDM patients. Although it is a fairly rare condition, DKA in pregnancy can compromise both fetus and mother. Metabolic changes occurring during pregnancy predispose to DKA in fact it can develop even in setting of normoglycemia. This article will provide the reader with information regarding the pathophysiology underlying DKA, in particular euglycemic DKA, and will provide information regarding all possible effects of ketones on the fetus.

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

BACKGROUND

Observing the fast during the holy month of Ramadan is one of the five pillars of Islam. Although pregnant women and those with pre-existing illness are exempted from fasting many still choose to fast during this time. The fasting behaviours of pregnant Muslim women resident in Western countries remain largely unexplored and relationships between fasting behaviour and offspring health outcomes remain contentious. This study was undertaken to assess the prevalence, characteristics of fasting behaviours and offspring health outcomes in Asian and Asian British Muslim women within a UK birth cohort.

METHODS

Prospective cohort study conducted at the Bradford Royal Infirmary UK from October to December 2010 comprising 310 pregnant Muslim women of Asian or Asian British ethnicity that had a live singleton birth at the Bradford Royal Infirmary. The main outcome of the study was the decision to fast or not during Ramadan. Secondary outcomes were preterm births and mean birthweight. Logistic regression analyses were used to investigate the relationship between covariables of interest and women's decision to fast or not fast. Logistic regression was also used to investigate the relationship between covariables and preterm birth as well as low birth weight.

RESULTS

Mutually adjusted analysis showed that the odds of any fasting were higher for women with an obese BMI at booking compared to women with a normal BMI, (OR 2.78 (95% C.I. 1.29-5.97)), for multiparous compared to nulliparous women(OR 3.69 (95% C.I. 1.38-9.86)), and for Bangladeshi origin women compared to Pakistani origin women (OR 3.77 (95% C.I. 1.04-13.65)). Odds of fasting were lower in women with higher levels of education (OR 0.40 (95% C.I. 0.18-0.91)) and with increasing maternal age (OR 0.87 (95% C.I. 0.80-0.94). No associations were observed between fasting and health outcomes in the offspring.

CONCLUSIONS

Pregnant Muslim women residing in the UK who fasted during Ramadan differed by social, demographic and lifestyle characteristics compared to their non-fasting peers. Fasting was not found to be associated with adverse birth outcomes in this sample although these results require confirmation using reported fasting data in a larger sample before the safety of fasting during pregnancy can be established.

Ramadan fasting and newborn's birth weight in pregnant Muslim women in The Netherlands

Many Muslim women worldwide are pregnant during Ramadan and adhere to Ramadan fasting during pregnancy. In the present study, we determined whether maternal adherence to Ramadan fasting during pregnancy has an impact on the birth weight of the newborn, and whether the effects differed according to trimester in which Ramadan fasting took place. A prospective cohort study was conducted in 130 pregnant Muslim women who attended antenatal care in Amsterdam and Zaanstad, The Netherlands. Data on adherence to Ramadan fasting during pregnancy and demographics were self-reported by pregnant women, and the outcome of the newborn was retrieved from medical records after delivery. The results showed that half of all the women adhered to Ramadan fasting. With strict adherence to Ramadan fasting in pregnancy, the birth weight of newborns tended to be lower than that of newborns of non-fasting mothers, although this was not statistically significant ( - 198 g, 95 % CI - 447, 51, P= 0·12). Children of mothers who fasted in the first trimester of pregnancy were lighter at birth than those whose mothers had not fasted ( - 272 g, 95 % CI - 547, 3, P= 0·05). There were no differences in birth weight between children whose mothers had or had not fasted if Ramadan fasting had taken place later in pregnancy. Ramadan fasting during early pregnancy may lead to lower birth weight of newborns. These findings call for further confirmation in larger studies that should also investigate potential implications for perinatal and long-term morbidity and mortality.