Impact of maternal fasting during Ramadan on fetal Doppler parameters, maternal lipid levels and neonatal outcomes

The impact of Ramadan fasting on oxidative stress levels in the second trimester of pregnancy

BACKGROUND

The primary objective of this study was to assess the effect of fasting during Ramadan on maternal oxidative stress levels and foetal development; pregnant women with uncomplicated, singleton pregnancies in the second trimester.

METHODS

During the month of Ramadan, 23 March 2023 to 20 April 2023, 50 fasting and 50 non-fasting healthy pregnant women were enrolled in this prospective study. The fasting hours were about 14 h per day in that season. Pregnant women in the second trimester were enrolled in the study. Total antioxidant status (TAS), total oxidant status (TOS) and the oxidative stress index (OSI) were measured from maternal serum samples taken on a fasting day at the end of Ramadan. To evaluate the impact of Ramadan on the foetus, Doppler ultrasonography was performed in the beginning and then at the end of Ramadan in all participants and was used for the following measurements: Increase of biparietal diameter, femur length, estimated foetal body weight, amniotic fluid index and umbilical artery systolic/diastolic ratio. To discern differences between distinct cohorts, independent t-tests and Mann-Whitney's U-tests were employed based on the data distribution. A p value threshold of less than .05 was established to determine statistical significance.

RESULTS

TAS level was found to be significantly lower in the group that fasted for more than 15 days compared to the non-fasting group that did not fast (p = .003), but no significant differences were found between the groups in terms of TOS and OSI (p < .05). Obstetric ultrasound parameters showed no significant differences between the two groups (p < .05).

CONCLUSIONS

The present study suggests that fasting during the second trimester of pregnancy does not substantially impact maternal or foetal health, as indicated by most oxidative stress markers and foetal parameters studied. However, the observed reduction in the TAS levels in the fasting group warrants further investigation.

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.

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.

Predictors of Poor Neonatal Outcomes among Pregnant Women in Indonesia: A Systematic Review and Meta-Analysis

OBJECTIVES

This study aimed to examine the association between maternal health behaviors and neonatal outcomes among the Indonesian population.

METHODS

Articles were collected from PubMed, EBSCO, ProQuest, DOAJ, and GARUDA. Funnel plots and Egger's tests analyzed indications of publication bias. A Mantel-Haenszel random-effects model was used to see the overall effect size of exposures on outcomes. Heterogeneity was seen based on I2. Data collected from articles included the author, year of publication, location of the study, study design, number of samples, risk factors, and effect sizes.

RESULTS

We identified 24 relevant studies, including eight from the primary databases and 16 from an additional database. A total of 12 studies were included in the meta-analysis, examining the association between maternal health behaviors and neonatal outcomes. The pooled odds ratio (OR) for passive smoking and low-birth-weight (LBW) was 3.41 (95% CI: 1.75-6.63, I2 = 40%, four studies). The pooled OR for incomplete antenatal care (ANC) and LBW was 6.29 (95% CI: 2.11-18.82, I2 = 70%, four studies). The pooled OR for incomplete ANC and neonatal mortality was 2.59 (95% CI: 1.01-6.66, I2 = 93%, four studies).

CONCLUSIONS

The results indicated that pregnant women with incomplete ANC had a higher risk of LBW and neonatal mortality, and those who were passively exposed to smoking had a higher risk of LBW. Further investigations are needed, considering the high heterogeneity found, and additional meta-analyses should be based on the variations of socio-demographic conditions.

Effect of a standardized maternal meal on fetal middle cerebral artery Doppler indices: A single-blinded crossover study

Objective

Measures of Doppler blood flow velocity profiles are an integral part of monitoring fetal well-being during pregnancy. These examinations are performed at different times of the day and at different maternal meal states. In uncomplicated pregnancies, we assessed the effect of a standardized maternal meal on middle cerebral artery (MCA) and umbilical artery (UA) Doppler blood flow velocity pulsatility indices (PIs) and MCA peak systolic velocity (PSV).

Methods

In this prospective single-blinded crossover study 25 healthy women were examined at 36 weeks of pregnancy. The first examination was performed in the morning following overnight fast, and repeated after extended fast (state A), and after a standard breakfast meal (state B).

Results

Irrespective of maternal prandial status, the MCA-PI values were lower in the 2^nd compared to the 1^st examination (-0.187; p = 0.071, and -0.113; p = 0.099, state A and B, respectively). Compared to the values in the 1^st examination, the UA-PI values, were higher after extended fast (0.014; p = 0.436), and lower post-prandially (-0.036; p = 0.070). The difference (state B minus state A) between the meal states were not significant (0.074; p = 0.487 and -0.050; p = 0.058, for MCA-PI and UA-PI, respectively). Adjusting for the possible influence of fetal heart rate on MCA-PI and UA-PI, the differences between meal states remained non-significant (p = 0.179, p = 0.064, respectively). The MCA-PSV values increased after the meal (6.812; p = 0.035), whereas no increase was observed following extended fast (0.140; p = 0.951). The difference in MCA-PSV values between the two meal states was not significant (6.672; p = 0.055).

Conclusion

Our results demonstrate possible diurnal variations in MCA-PI and UA-PI, with and without adjustment for fetal heart rate, that seem to be unaffected by maternal meal intake in healthy pregnancies.

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 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.

The effects of prenatal exposure to Ramadan on stature during childhood and adolescence: Evidence from the Indonesian Family Life Survey

Many pregnant Muslim women fast during the Muslim holy month of Ramadan. A number of studies have reported negative life outcomes in adulthood for children who were prenatally exposed to Ramadan. However, other studies document minimal to no impact on neonatal indicators. Using data from the Indonesian Family Life Survey consisting of 45,246 observations of 21,723 children born to 9771 mothers, we contribute to the current discussion on prenatal exposure to Ramadan by examining the effects on stature (height-for-age Z-scores, weight-for-age Z-scores, and body-mass-index-for-age Z-scores: HAZ, WAZ, and BAZ, respectively) from early childhood to late adolescence (0-19 years of age). We introduce an objective mother's religiosity indicator to improve the intention-to-treat estimations. Children were classified into three groups based on their mother's religion-religiosity: religious Muslims, less-religious Muslims, and non-Muslims. Using cluster-robust mother fixed-effects, we found negative effects on stature for children born to religious Muslim mothers. The effects were age-dependent and timing-sensitive. For example, children born to religious Muslim mothers were shorter in late adolescence (15-19 years of age) compared to their unexposed siblings if they were prenatally exposed in the first trimester of pregnancy (HAZ difference = -0.105 SD; p-val. <0.05). Interestingly, we found positive effects on stature for exposed less-religious Muslim children that peak in early adolescence (10-14 years of age) and negative effects on stature for exposed non-Muslim children that occur only in early childhood (0-4 years of age). We nuance our discussion of health and socioeconomic factors to explain these surprising results.

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.

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.

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.

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.

Impact of maternal fasting on fetal well-being parameters and fetal-neonatal outcome: a case-control study

OBJECTIVE

To assess the impact of maternal fasting on fetal well-being parameters and neonatal outcome.

METHODS

Two-hundred ten healthy women with singleton uncomplicated pregnancies at 36-40 weeks' gestation who had fasted for 12-16 h were defined as the study group with 240 healthy non-fasted pregnant women matched for age, parity and gestational age were defined as the control group. Both groups were subjected to tests of fetal well-being in the form of non-stress test (NST), modified biophysical profile and Doppler indices of the umbilical and middle cerebral arteries (MCA). Women were followed-up till delivery to record the obstetric outcome.

RESULTS

There was no significant difference between the two groups regarding the reactivity of NST, modified biophysical scores, Doppler indices of the umbilical and MCA (resistive index, pulsatility index and systolic/diastolic ratio) and the cerebroplacental ratio (p > 0.05). There was no significant difference between the two groups regarding the gestational age at delivery, mode of delivery, neonatal weight, 5-min Apgar scores and admission to neonatal intensive care unit (p > 0.05).

CONCLUSIONS

Short-term maternal fasting has no deleterious effect on fetal well-being parameters or neonatal outcome. Pregnant women who desire fasting, should be reassured regarding the health of their babies.

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.