This study was conducted to compare the pregnancy outcome and perception of women who fasted during the second trimester of current pregnancy with women who did not fast. About 80% of the women in the fasting group in this study fasted for 21–29 days during Ramadan, out of whom 38.7% completed fasting for the entire period of Ramadan. Similar fining has been reported in a study conducted by Ziaee el al. who observed that 31.7% of the mothers in their study conducted in Iran fasted for the entire Ramadan [23]. In the present study, no association was found between preeclampsia, mode of delivery, LBW, 5th minute Apgar score, newborn birth weight, height and head circumference, and fasting behaviors.
Our study is consistent with other studies which did not find an association between fasting and fetal anthropometrics measurement. In a cross-sectional study by Arab et al. in which the relationship of maternal fasting and newborn birth weight was assessed [24], it was found that Ramadan fasting did not affect the birth weight of newborns. Almond et al. found statistically insignificant decrease in the birth weight of newborns when Ramadan fasting occurred during the third trimester of pregnancy [10]. Another study conducted in Iran showed that Ramadan fasting during the third trimester of pregnancy did not alter neonatal anthropometric measurements [25].
In a prospective cohort study conducted at the UK, comprising 310 pregnant Muslim women of Asian or Asian British ethnicity, no associations were found between fasting during pregnancy and low birth weight and birth weight of the newborns [15]. In another study by Jamilian et al., no statistical difference was found between fasting and non-fasting mothers in terms of fetal heart rate, fetal movement, mode of delivery, birth weight, birth height, head circumferences, and Apgar score [26].
Examining the effect of fasting behavior on pregnancy outcomes in this study revealed that the women who did not fast during the second trimester of pregnancy were 1.51 times more likely to develop gestational diabetes. It was also found that among the women in the fasting group, those who fasted for 21–29 days during pregnancy had a lower risk of gestational diabetes compared to the other groups. This study revealed that the average weight gain during pregnancy in fasting women was lower than non-fasting group, particularly in women who fasted for more than 20 days during second trimester of pregnancy. It has been suggested that this decrease in body weight during Ramadan could be attributed to a decrease in fluid intake [27, 28]. It can also be a result of decrease in glycogen-bound water stores, extracellular volume contraction secondary to a lower sodium intake, and a moderate degree of hypohydration with little loss of body tissue [29]. There is evidence that excessive gestational weight gain in early pregnancy may increase the risk of GDM in pregnant women [30]. Although the exact mechanism of how excessive weight gain may contribute to gestational diabetes is unknown, researchers hypothesize that rapid weight gain early in pregnancy may increase insulin resistance which in turn leads to the “exhaustion” of the beta-cells in the pancreas that produce and release insulin which controls the level of glucose in the blood. This could reduce the capacity of the beta-cells to secrete adequate levels of insulin to compensate for the insulin resistance induced by the progression of pregnancy and therefore lead to the development of gestational diabetes [31]. In the studies conducted by Mirghani et al. on pregnant women who fasted intermittently during Ramadan, fasting blood glucose levels in the fasting mothers significantly decreased compared with the non-fasting mothers [13, 32]. Caloric restriction studies revealed that intermittent fasting changes the fuel selection and improves the metabolism efficiency while reduces oxidative stress [33,34,35]. The results of a prospective observational study by Afandi and colleagues in 2017 on 32 patients with GDM indicated that glucose levels were better in those women with GDM fasting in Ramadan than pre-Ramadan whether they were treated with diet plus metformin or diet only, and they had the highest rate of normoglycemia (90.2%); however, the higher rate of hypoglycemia was observed in the women with GDM [36].
In contrast with the present study, the results reported by Mirgani et al. showed that maternal diet restriction is associated with an increased maternal risk of gestational diabetes mellitus [37]. In a study by Al Ketbi et al., the mean random blood glucose level was significantly higher in the fasting group comparing with the control group 1 h after breaking the fast (p = 0.002) [38]. However, similar to other studies that assessed the biochemical changes in mothers fasting during pregnancy, association of these changes with gestational diabetes was not analyzed [3]. Moreover, most studies reporting negative impacts of prenatal Ramadan fasting were conducted without access to reported fasting data; therefore, they were unable to examine the potential role of exposure duration [10, 39, 40].
The present study gives a clear insight into the perceptions of fasting among Iraqi women during pregnancy. It has been revealed that the decision to fast during pregnancy was negatively associated with the mother’s educational level and occupation, such that with an increase in the education levels and frequency of working, fewer mothers fasted. This finding is consisted with the results found by Nusrat and colleagues in Iran who observed that a higher number of the mothers in the fasting group had lower education levels [41].
A higher number of mothers in the fasting group perceived that fasting during pregnancy was compulsory for healthy and non-healthy mothers, comparing with mothers who did not fast. This indicates that they were unaware of the permissibility and exemption of fasting in Islam during pregnancy, or there is a lack of communication by the nurses and other healthcare staff to provide efficient and relevant prenatal information for pregnant women [3].
This study suggested that participation to Ramadan fasting was mostly associated with the fact that the mother were reluctant to repay the fasting after pregnancy. The same response was observed by Pakistani women when they were asked about their reason for fasting during pregnancy [5]. It may indicate that women would like to fast with their families rather than doing this alone later. Uncomfortable feeling while they were eating in the presence of family was found as another reason for fasting in this study. On the other hand, just 2.8% of the mothers in the non-fasting group were encouraged not to fast during pregnancy. It may associate with the role of gender in Iraq where the role of women is diminished in the family and society according the prevailing culture in society [42]. Research has revealed that husband’s opinion affects a woman’s decision to fast, so that women are less likely to fast if their husband supports and encourages them not to fast [43].
In Islam, pregnant women are allowed not to observe fasting if they are concerned about risking their and their fetus’s health [5, 44]; however, just 2.8% of the non-fasting mothers did not fast because of this belief. On the other hand, just 28.57% of the fasting mothers stopped fasting when they were advised by the obstetrician. This could reflect how they perceive the rule for fasting in pregnancy or how their healthcare staff failed to provide them with relevant and efficient information.
Hunger or thirst was the most discomfort experienced by the fasting mothers during pregnancy. Metzger and his co-workers first defined accelerated starvation signs in pregnant women when skipping breakfast after nocturnal fasting in comparison with non-pregnant women [45].
To the best of the authors’ knowledge, the present study is the first investigation that has been conducted in Iraq in order to assess the perspectives and pregnancy outcomes of maternal Ramadan fasting; however, this study should be considered in light of its limitations. Since interview was performed at the time of birth, the possibility of recall bias for the data regarding fasting increased. A further limitation may be the external generalizability of these results to wider Muslim populations which may comprise different traditions, dietary habit, and beliefs about fasting. Another limitation of the present study is it only included women who fasted during the second trimester of pregnancy, and the effect of fasting on pregnancy in different trimester of pregnancy cannot be compared.
