Religious practices of Muslim women in the UK during maternity: evidence-based professional practice recommendations

Abstract

Background

Muslim women commonly observe certain religious practices during their maternity journey and research in this area suggests that more could be done from a service provision perspective to support Muslim women in the UK through this significant life event.

Aim

This study identifies Muslim women’s religious practices during maternity, needs and challenges of religious practice while engaging with maternity services, and support needs from healthcare professionals.

Method

Qualitative mixed method study; that includes eight longitudinal interviews with first-time pregnant Muslim women, five focus groups with 23 Muslim mothers experiencing childbirth in last three years in UK, and 12 one-to-one interviews with Health care Professionals (HCPs) with previous experience working with Minority Ethnic groups. Participants recruited from local Muslim community groups and Maternity Care Provider, North West Coast, England. Data analysed using thematic analysis.

Result

Qualitative findings indicate common religious practices that Muslim women exercise at different stages of their maternity journey. These practices can be divided into two categories of common religious practices for Muslim women that 1) require only healthcare professionals’ awareness of these practices and 2) require awareness and active involvement of healthcare professionals. Findings highlight key recommendations for healthcare professionals when addressing Muslim women’s religious needs in the UK.

Discussion/Conclusion

This study provides evidence-based recommendations for professional practice to assist healthcare professionals in developing understanding and addressing Muslim women’s religious practice needs in the UK. Further research is required to explore the impact of these recommendations for professional practice.

Background

Over recent years the UK has focused on enhancing the quality of maternity care and has encouraged a personalised and woman-centred approach that acknowledges that every woman is different in terms of her needs (cultural, religious and social) and choices [1]. Moving forward with the practical application of this approach is important given the growing diversity of the UK population.

The Muslim population makes up the second largest religious group in the UK and this population continues to increase [2]. Even though Muslims living in the UK are not a single homogenous group (being instead culturally, ethnically and linguistically diverse communities) [3], an overwhelming majority of Muslims in the UK will respect the rites of passage recommended by Islamic teaching [4]. Research has highlighted that Islamic beliefs and practices were at the core of Muslim women’s maternity experiences [5]. Whilst these practices provided a resource for Muslim women when faced with struggles during childbirth, many Muslim women lacked confidence to express their religious needs when engaging with maternity healthcare services [5]. A recent review of Muslim women’s experiences of maternity services in the UK highlighted that healthcare professionals appeared insensitive to Muslim women’s needs due to a lack of understanding of the religious values and practices, which impacted Muslim women’s confidence in discussing their specific needs [6].

This finding demonstrates the importance of understanding the religious practices during maternity of Muslim women and their impact within maternity services. Rassool suggests that healthcare professionals who have an understanding of Muslims’ worldview and religious/cultural practices are better placed to provide woman-centred care [7]. Swihart and Martin highlight the importance of empowering healthcare professionals with the knowledge and skills to respond to the religious/cultural needs of patients and their families [8]. Hasnain et al., also reported that whether in the United States or Western countries, improving care for Muslim women would require a care model that included training health care professionals and made necessary adjustments in the healthcare system to accommodate for women’s needs [9].

This paper describes Muslim women’s religious practices during maternity, through both the perspective and experiences of Muslim women and healthcare professionals, to provide evidence-based recommendations to help assist healthcare professionals when providing woman-centred care for Muslim women. The aim is enhancing awareness and understanding of Muslim women’s needs amongst healthcare professionals, encourage better interaction and build Muslim women’s confidence in expressing their needs.

Methods

This paper presents findings from a three-phase qualitative study that explored Muslim women’s experiences of motherhood while engaging with NHS maternity services [5, 10]. A qualitative research design offered flexibility to Muslim women and HCPs in discussing their perceptions and experiences of Muslim birth practices. Having both perspectives created a deeper insight into how religious practices are acknowledged in relation to maternity services.

Participant recruitment

There were three phases of participant recruitment to the study, the details of each phase is highlighted in Table 1.

Table 1 Study research design and recruitment

Data collection

One-to-one and focus groups interviews were conducted between 2013 and 2016 in locations suitable for each participant, this included women’s own homes, local community centres, women’s group settings, maternity care Trust and coffee shop. Interviews and focus groups were approximately 60–90 min long. A semi-structured interview guide was used that included open questions that focused on Muslim women, religious practice and how this practice influenced maternity experiences and how these experiences can be acknowledged and addressed. Recruitment and interviewing continued until data saturation was achieved; that is, when no new information emerged from new data collected. Participants provided written informed consent prior to interview.

Data analysis

Audio-recordings were transcribed verbatim by (SH) and reviewed by the study’s supervisors (CL), (KB) and (JR) for consistency and credibility. Data from each phase of the study was analysed using a structured thematic analysis approach [11] to identify, analyse and report key themes within the data. All main themes from across the three phases were combined to identify key overarching recommendations. The themes identified in this three-phase study included; Muslim women’s spiritual perspective; Muslim women’s expression of religious requirements; HCP’s perceptions about Muslim women; HCP’s understanding and awareness of religious practices; HCP’s approaches in addressing and supporting Muslim women’s religious needs; Importance of training in providing culturally and religiously appropriate woman-centred care which are reported elsewhere [5, 10]. This paper’s analysis focused on themes identified highlighting Muslim women’s religious practice and presented these findings in detail building on recommendations that provide detailed insight to Muslim women’s religious practices in the UK. Final identified recommendations were reviewed by the supervision team, two healthcare professional and a public adviser (Muslim woman).

Ethical consideration

The ethic approval was obtained from the NHS Research Ethics Committee (through the Integrated Research Application System (IRAS) [REC reference: 13/WS/0087; IRAS project ID: 117529]) prior to commencing data collection. Written consent was obtained from all participants in the study.

Results

Forty-three participants discussed Muslim women’s birth practices and their implications when engaging in maternity care services. When participants were asked about their religious practices during their motherhood journey they discussed different aspects such as the religious practices recommended by religion, the practices that they planned to implement, and the practice that they were unable to implement. All religious practices reported by all participants in this study and in which period of maternity they were practiced are highlighted in Table 2. Note, all participants are given a code or a pseudonym name.

Table 2 Religious practices mentioned by participants

Recitation of Quran and supplications

The recitation of the Quran is the first and most constant religious practice carried out by participants throughout the stages of childbirth. Through the recitation mothers reflect on Allah’s words as a form of worship. All participants had plans for the Quran recitation to be played using an audio device during the early stages of their labour. Some requested a CD player from their midwives to play the Quran recitation in the room they are staying in during Labour and some used their own devises such as using a mobile phone. Some had Muslim birth partners or sought Muslim healthcare professionals to assure that the religious practices were fulfilled.

‘I wanted the recitation to be played and someone reciting certain supplications next to me. That is why I really wanted Muslim sisters to be there and not my non-Muslim family, because if I had gone in with my non-Muslim family and friends, I would have been too weak and I would have just been overpowered and none of it would have happened.’ (Gp3; P3).

‘I remember a lady on antenatal clinic who used to play the Quran every evening just to calm herself down. Either play it or read it’. (HP-6).

Through supplication mothers would ask Allah for ease at the time of their struggles and for the protection of their child. Some women mentioned certain attributes of Allah that they will call out during supplications that relate to their need, especially during labour, such as Al- Latif (The Gentle), Al-Karim (The Generous) and Al-Wadud (The Loving One).

‘I remember my sister making me call it out and the midwives were watching me. I had to do it and my midwife was there and they said it was amazing.’ (Gp4; P2).

Maintaining modesty

In this study modesty was discussed by all participants; for the majority of participants the main concern was to maintain their modesty during labour and during examinations. It was important for them not to be too exposed during labour; for some, this concern was causing them anxiety as to whether they would be able to maintain it at all times, and whether their midwives would acknowledge this concern.

‘For me I think modesty definitely ties in with my religion, you are not just going to let it go because you are having a baby, so you have to hold on to your belief.’ (Noor).

Some healthcare professionals were aware of this and used available resources such as extra sheets to make sure the women feel comfortable during labour or clinical examination.

‘I saw a lady a while ago who wore the full Burku, a face veil, which you might think would be difficult but I took her to a private room as she had difficulty with breastfeeding. She was very happy for me to remove her veil to see how the baby fed.’ (HP-10).

Sahar explains how her midwife recognised this need and acted to deliver it.

‘When they put me on the wheelchair to go and get my stitches, I never had a head scarf and they were going to take me out of the room. I said to my husband can you please pass me my head scarf and I think that was the first time my midwife actually realized I am a Muslim. Then she said, “get the sheet and cover her (my) legs”. It is then that she made more of an effort.’ (Sahar).

Absences of male healthcare professionals

All mothers preferred not be seen by male healthcare professionals during scan appointments, clinical examinations or attending during their labour. Participants explained that religion gives them an exception during the unavailability of a healthcare professional of the same gender to be attended to by the opposite gender. However, participants had different opinions on how they would approach this situation; for some if a female is not available then they would take the religious exception, others would request their appointment to be rescheduled with a female, and some did not feel confident enough to ask about whether a female healthcare professional was available to attend to their care. They felt that the healthcare professionals would not acknowledge this need, and they might be considered as a burden through what they believed—that their need is an extra demand on the services.

‘I was seen by a man healthcare professional, I actually felt very uncomfortable but I felt I like I was in a situation where I could not even say to him “can I have a woman” … I feel like he may think “Oh here we go, a Muslim woman complaining” or “Oh she is making more work on us’ (Samah).

However, during labour some participants were in a situation where male healthcare professionals had to be involved for medical reasons. Some felt that they would only accept to be seen by a male professional once they were in a critical situation and they had insisted on being attended to by a female professional.

‘The midwife told me there is only so much she can do but she needs to get the doctor in, then I said ok, can I not have a man. They went back and tried; there was a female doctor that just about come out of her shift then she just stayed and helped me through labour.’ (Gp4; P3).

Some healthcare professional participants reported that they would try and explore if a Muslim woman was happy to be seen to by a male professional and try to give her the opportunity to express her preference.

‘I say to them in a subtle way, we have got a male and a female doctor on today, so is that okay? And I give them that opportunity then to say to me, well, actually can I see the female? And I will say, yeah, that is fine, no problem. And I put a note on, female only. If I have two male doctors on, which does not happen too often, but if it does happen, I will say to them, both of our doctors today are male, how do you feel about that? And they are like, no, no, I'm not going to see a male. Or they might say, that is fine.’ (HP-8).

Fasting the month of Ramadhan

There was a difference in opinion amongst participants in whether they would observe the fast while pregnant or breastfeeding, even though their religion exempts them from observing the fast during this period. Most participants attempted to fast, if they felt that they were physically unable to tolerate the fast, they would then consider the exception. More than half of the participants said that Ramadhan is a spiritual month that all the community engages in, therefore it is difficult for one to make a choice to not engage in this community worship. The majority of health care professionals did not agree to fasting during pregnancy and some acknowledged and respected choice in fasting.

‘I remember when I was pregnant it was Ramadhan and I was doing one day on and one day off of fasting… The midwife said to me “you know yourself and listen to your body” and “you can do what you want to do” and she respected that. It made me feel good that she respected.’ (Gp2; P4).

Meanwhile, the majority of participants said that they would not mention the fast to their midwives. They explained that midwives would often advise against fasting during pregnancy. Healthcare professionals in this study reported that they would advise the women not to fast and reflect on the religious prospective, however, they felt that some women wouldn’t consider their advice.

‘All you can say is, we prefer you not to fast in pregnancy, you are immune from fasting while you are pregnant or breastfeeding, so please do not do it. But I know that most women will still fast and some women miss the appointments because they are fasting’. (HP-4).

‘If only they have leaflets on fasting while pregnant or breastfeeding because it is not easy just to tell someone to not fast. So it is nice to have something that is fixable and just informs the mother on what she can do and eat to make sure that she is still healthy while fasting, like what food and drinks to have when breaking the fast.’ (Fatimah).

Eating dates during initial stages of labour

Eating dates during the early stages of labour is common amongst the majority of participants. They highlighted the eating of dates during the early stages of labour is religiously recommended, as it is considered as a form of pain relief and an energy source. The majority of participants started to eat dates while still at home as soon as labour pains came about, they also continued to have the dates during the early stages of labour in hospital. Mothers explained that this practice can be difficult to maintain during their following pregnancy, labour can often be very spontaneous and fast giving no time to have dates.

‘Obviously when you pack the hand bag that you bring with you to the hospital, we make sure we take dates with us. So, before you look at science, if you are a person of religion you are going to look at how religion teaches you and you learn that it tells you to have dates to ease labour.’ (Salee).

Silent birth

This practice was mentioned by some participants; they explained that they preferred to have silent in the labour room when their child is born or for everyone attending the birth refraining from speaking words as much as possible. This is because they believed that the first words that their child should hear are the words of Allah. Some participants reported that their midwives acknowledged this when they mentioned it on arriving at the hospital. However, like most mothers, other participants did not feel confident enough to mention this practice to their midwife; one participant tried to compromise by calling out the name of Allah in a slightly higher voice then the voices in the room in order for her baby to hear the word of Allah first.

‘That was something that I made sure of and that the midwives do not speak, and the first word to be Allah. I think my husband vocalised that too and said to the midwives “can we please have silence” and I think they would have completely respected it and they were really good like that.’(Noor).

Burying the placenta

The burial of the placenta was mentioned by all the participants as an Islamic recommended practice; they explained that as it is an obligation to bury the dead human body and it is encouraged to bury any separate part of the human body if possible out of respect. All the participants wished to do this practice but the majority found it difficult to practise without having the facilities. They explained that a common practice is that the placenta is buried in the garden of one’s home but because they do not have a garden and were not sure of any other option they have decided not to engage in this practice. Only two participants managed to do this practice and as for mothers only a few managed to bury their placenta.

‘I put down that I want the placenta because of religious beliefs that we do not incinerate any human parts and I think in the hospitals they incinerate the placentas.’ (Noor).

Adhan and Iqamah [call of prayer]

This practice was considered as one of the most important practices carried out by mostly the birth partners; religiously it is recommended to whisper the Adhan [call of prayer] into the baby’s right ear and the Iqamah into the left ear. This is considered as a significant religious ceremony that is highly recommended to take place first thing when the child is born. Although the majority of participants and their birth partners were confident to implement this ceremony with the presence of the midwives in the room, they were not confident enough to fully inform or explain to the midwives what they were doing or intended to do. The majority of participants said that midwives or the staff that were in the room were busy completing what they had to do and did not notice the practice. Generally, all participants said that they would have appreciated less talking in the room while this was practised. Two participants reported their midwives acknowledged this and remained quiet while their partner completed the practice; meanwhile similar to some mothers from the focus groups and interviews, they had to delay this practice until the midwives had left the room.

‘I wanted her to hear the Adhan for me and my husband that is so important. The baby was passed to my husband. So I said “we need to read something for the baby, can you please be quiet while we do that” they just said “ok” and they just continued talking and whispering. It was clear that they did not understand what we were doing.’ (Sahar).

‘We could not do it, we hid away. When my husband took the baby and went to one side, the midwife was like “where is he?” “What has he done with the baby?” And she kept on asking and she was like “we really need to clean him now” and she was trying to take the baby.’ (Gp4; P1).

Tahneek

This practice was another reason why the participants prepared dates to bring into hospital for labour. It is recommended that soon after the birth before the baby’s first feed, for the mother or the birth partner to take a small piece of softened date and gently rub it into the baby’s mouth. Some participants practised this as recommended, they had dates with them in the hospital and others practised once they arrived home after the baby’s first feed. Meanwhile all participants avoided doing this practice while midwives or staff were still present in the room; they explained that staff may consider this as taboo and would discourage it. So, to avoid being discouraged, all participants delayed this practice until no healthcare professional was present.

‘I did not want them to think that I am not a good mother and say “look she is putting solids in his mouth”. I did not want them to take it to that extreme. So that was quite a personal time for me, I just wanted them to leave, so I can do it while they were busy.’ (Gp2; P3).

Some participants mentioned that they read an article referring to scientific research that highlights the possible benefits of given a new-born sugar gel by rubbing it in the inside cheek of premature babies to protect against brain damage. Samah, Fatimah, Noor and other mothers said they find it more beneficial when science backs up their religious practice, as it helps in removing the taboo of the practice.

‘My husband did the Tahneek when the midwife left the room because she would not understand. There is research that has just come out about giving a new-born child sugar can help protect them from brain issues. For the health professionals it is nice to have evidence to back up our practice.’ (Samah).

Animal-based products in pharmaceuticals

There are a large number of animal products in pharmaceuticals that can possibly present Muslims with a serious dilemma; weighing their health against their religious principles. This concern was raised by a few participants in this study when the Vitamin-K injection given to the child at birth has some animal derivatives that are unlawful for Muslims. Some tried to find another alternative for the Vitamin-K that is free from any animal derivatives and some accepted the injection as it is for the benefit of the child health.

‘I mentioned that I did not want the Vitamin-K injection which was a big decision for me; I found out that the Vitamin-K actually has pig’s ingredients, which is completely prohibited in religion.’ (Noor).

Some mothers from the focus groups were also in a similar situation and suggested that the maternity services should have a product free from animal derivatives available in the hospital. The majority of participants were not aware that the Vitamin-K injection may not comply with their religious beliefs and presumed that they would have been informed of animal-based pharmaceuticals because they believed that healthcare professionals would be aware of their dietary needs.

‘I think the health professionals are well educated and I trust that. If there was something that is forbidden in other people’s religious or dietary needs, I think they are smart enough to tell us and it would be silly if they do not.’ (Hanan).

Breastfeeding

All participants in this study committed to breastfeeding. Participants were aware of the breastfeeding health benefits, however their commitment to breastfeed is mainly inspired through their religious teachings. Participants showed great understanding of the religious teachings regarding breastfeeding, they highlighted that in the Islamic traditions breastfeeding is a highly rewarded act, encouraging mothers to breastfeed her child for a maximum period of two years. Three participants explained that they considered the uptake of breastfeeding even though breastfeeding was not a common norm witnessed amongst their families.

‘In terms of breastfeeding, the Quran speaks about the blessing and rewards of this act and even how long you should breastfeed for. The breast milk is pure and she is born a Muslim, where I was not. I want to give her the best start as much as Islamic influence as possible. I was concerned that I probably would not succeed in breastfeeding but I persevered because of the Islamic element. I understood that there is a reward and blessing in this act and that mainly pushed me to do it.’ (Sahar).

There are many challenges in breastfeeding. Most mothers mentioned that they sought support from midwives, breastfeeding support team and family and friends while trying to establish breastfeeding with all their children. All participants explained that support during the early stages of breastfeeding is key in helping them persevere.

‘I know a lot of girls see breastfeeding as a natural thing but the reality of it is that it is hard and the struggle of it is hard. Unless you have someone around you guiding and supporting you, I can imagine a lot of girls just quit.’ (Gp1; P1).

However, healthcare professional participants fund that the majority of Muslim women would already have their mind set on breastfeeding and they are normally very good in initiating and maintaining breastfeeding. For some they believed that Muslim women have support within the community to help them in breastfeeding.

“They will always know somebody who's breastfed. They have got women, very supportive women in the community, they have all breastfed before, someone's going to help them do it”. (HP-4).

Participants found breastfeeding challenging in the presence of others or in public. The majority of participants said that they would stay home most of the time to avoid breastfeeding in public. Even in front of other women, some participants did not feel confident enough to breastfeed because they felt a bit exposed. Using a breastfeeding apron/cover helped some gain the needed amount of privacy with their baby while breastfeeding.

‘I would like to breastfeed my own child indoors and I would not feel comfortable to go and breastfeed somewhere else. Even at the hospital ward I had to make sure that the curtain was always closed.’ (Khadija).

Male circumcision

This practice was discussed by three women from the interviews and many mothers from the focus groups who have had male children. The participants explained that this practice was an important religious requirement that has no religious exceptions and one cannot be laidback about. It is recommended for the male child to be circumcised as early as seven days after birth; all participants aimed for their children to be circumcised early as it is recommended but most found it difficult. All participants explained that they lacked information regarding how and where circumcision can be done. They were keen on seeking a safe and reliable circumcision clinic. Before making a decision on how or where to do the circumcision, mothers tried to source information from NHS services, family and friends, and Muslim healthcare professionals within the local community.

I went to the children’s hospital and they do not do it early because of the risk of putting the baby to sleep. With my first, I did not want to go to a private surgery just in case anything goes wrong because with the NHS it has its standards and they will follow it up if anything goes wrong.’ (Gp4; P4).

The majority said that the NHS was the first place they sought, however, difficulty in doing this practice in the NHS meant that some participants had to find other alternatives. Some were in two minds whether to wait on the NHS or consider private circumcision clinics, which often made them feel anxious. Some sought private NHS accredited clinics that were trustworthy. Others followed the recommendation of other people who had used the private clinic for their children.

‘There are sisters that did not know that there are private clinics and they would wait for the NHS until their children are so much older, they are going to be in so much pain. Where I took my child it was so professional private doctor was amazing.’ (Gp3: P3).

However, there were mothers that chose to take a different route the second time they had to go through circumcision. Some mothers had their first child circumcised in the NHS but chose to take their second child to a private clinic. They explained that they realized that the earlier the child is circumcised the better and the quicker the healing process is. Other mothers had their first child circumcised in a private clinic and then decided to have their second child circumcised on the NHS. Some said that the circumcision of their first was not done appropriately, which then caused them to end up in the NHS, so they decided to not make the same mistake and just waited for the NHS for their second child.

‘My first boy was circumcised on the NHS and that was awful. I wish I did it when he was younger, all my sisters did it when their boys were 40 days and I wish did not wait until my child was a year. For my second one I am certainly going private and doing it within the first 40 days.’ (Gp2; P1).

All participants explained that they had no form of information given to them by the health services; they explained that they would have benefited and felt supported if they were provided with information on circumcision from the NHS and signposted to private clinics that are accredited by the NHS. Some healthcare professional participants said there is some awareness in the services about male circumcision, which they thought is important to help clear the confusion amongst the staff and also to help them direct Muslim women if they were to inquire about this matter.

‘I actually went to an event recently where there was some information about circumcision, which there is only a handful of centres that are certified. So I took the information and I thought, you know, in future if I get asked or if I wanted to send this information that this is what we can advise Muslim women that would be helpful’ (HP-6).

Shaving the hair of a new born

This was a practice that participants briefly discussed; traditionally on the seventh day of child’s life the scalp hair that has grown in utero is removed, and an equivalent weight in silver is given to charity. Some mothers engaged in this practice; once they were home the husband or a family member would shave the hair or bring someone to do so and distribute silver money that is equivalent to the weight of hair to the needy.

Aqiqah

This is a practice that was implemented by all participants. In the Islamic tradition, a sheep is offered in sacrifice for every newborn child as a sign of gratitude to Allah. This is recommended to take place on the seventh day after the birth of the child and the meat is distributed among family members and the needy. Some participants did the Aqiqah in a form of a celebration meal; the sacrificed sheep was cooked and served to family members and friends. As for others, the sacrificed sheep was divided into portions and given to family member and neighbours.

Community visits the mother after childbirth

It is a common tradition amongst Muslims to visit a mother after her birth; participants explained that visits start straight after birth and continue for two to three weeks. The purpose of these visits is to celebrate the coming of a new child and health of the mother. Visitors will bring food and gifts, and will sit with the mother for a friendly chat. Some participants said that these visits can be overwhelming, they explained that the first two weeks of the child’s life is the time for them to bond with their new born and get used to the changes that were happening in their lives. Some managed to send a message asking the community visiting to not visit in the first week after their birth, this gave them a chance to settle back home with their child. Meanwhile the others felt that it is impolite to stop people from visiting, they explained that it was a blessing to have people visiting you but it was difficult to maintain the demands of their child and hosting guests at the same time. Some participants stayed at their mother’s home and others had family members staying with them for support during this time. Most mothers praised this practice, they explained that it helped everyone to check on each other.

‘Traditionally we have visitors come see the baby but I was not very keen about them because you need time to get used to the changes that happen in your life with the baby coming in to it. But when the guests came you have to be very formal, presentable to people and talk to them.’ (Fatimah).

Religious practices and writing a birth plan

Finally, on reflection on religious practice and participants ability to express their needs in relation to these practice during their engagement with maternity services, every woman was given the opportunity to discuss and write anything specific to be acknowledged during labour. This can include her choice of pain relief, where she would like to give birth and any specific practice that she would like the midwife to be aware of. A birth plan sheet is provided in the handheld notes; many participants were not aware of this sheet. Even though participants expressed many practices that they were keen on implementing, the majority did not prepare a birth plan sheet. Some said that they do not think that midwives would have a chance to look through their birth plan at the point of labour and some said that they were not sure if the midwives would understand their religious needs.

‘My disappointing birthing plan appointment with my midwife that lasted 10 min of a simple tick list and just assumed things without asking me; Gas and air tick, information leaflet tick, birth at home no. She confused me so much that I forgot to mention some of the Islamic practices that I wanted to do during labour.’ (Sahar).

Mothers did not mention that they prepared a birth plan; none of the mothers seemed to be keen on writing out a birth plan. When they were asked if they had written a birth plan, many looked confused and were unaware of what a birth plan was.

‘It did not give me the option of mentioning any religious practice that I wanted to practise. Maybe it was not that black and white, maybe it was down to me to write it on there, but I do not think they have the time to look at it any way’. (Gp4; P1).

Discussion

The study identifies specific religious practices that Muslim women may engage with during their maternity journey and highlights their specific practice needs when engaging with maternity services. These practices and needs resulted in the development of practical recommendations to assist HealthCare Professionals (HCPs) to provide appropriate care for Muslim women.

Our findings add weight to existing evidence of the importance of enhancing person/woman-centred care that meets the needs of a growing diverse population in the UK. The Midwifery 2020 programme vision highlights the importance in maximising the potential for midwives to develop capacity and capability in delivering research-based practice in a changing environment [12]. The Five Year Forward View also suggests considering different approaches in how our maternity services need to change to meet the needs of the population [13]. Emphasising woman-centred care that prioritises the women’s individual needs that are defined by the women themselves, promoting choice, control and equitable care [14]. This proposition reflects the findings and recommendations of this study to contribute to enhancing maternity care for Muslim women and creating understanding of their specific needs as defined by them.

The findings of the study have practical importance given the evidence that minority ethnic women are still not receiving high quality maternity care for many reasons, which include judgmental and stigmatizing attitudes by health professionals [15], and are at higher risk of maternal mortality [16, 17]. Lack of understanding for example, of specific cultural/religious needs that may clash with certain medical routines, creates difficulties for ethnic minority women when engaging with maternity services [5]. Therefore, creating awareness and supporting healthcare professionals to enhance their understanding of cultural diversity is crucial for achieving an effective maternity service [3, 5, 6, 10].

The religious practices identified are organised into two categories of common religious practices for Muslim women that 1) require only healthcare professionals’ awareness of these practices (Table 3) and 2) require awareness and active involvement of healthcare professionals (Table 4). Final identified recommendations were reviewed by the supervision team, two healthcare professionals, an academic researcher and two public advisers (Muslim women).

Table 3 Common religious practices for Muslim women that require only healthcare professionals being aware of these practices

Table 4 Common religious practices for Muslim women that require awareness and active involvement of healthcare professionals

This study provides an in-depth insight into Muslim women’s religious practices, promoting better communications and interactions between women and health care professionals. Study findings also support Rassool’s suggestion to support healthcare professionals to develop levels of awareness, skills and religion/cultural sensitivity that can be applied to interactions with Muslim patients and their family [3].

Strengths and limitations

This study is the first of its kind to develop evidence-based recommendations concerning the care of Muslim women during pregnancy, based on the lived experiences and perceptions of Muslim women and HCPs. A Key strength of this study is that it presents details of universal Islamic religious practices narrated within Islamic teachings and tradition that have been practiced overtime and reflecting on how Muslim women in the UK experiences these practices. Also, this study has included the involvement of members of the public (including a Muslim woman and Muslim HCPs) who informed the recommendations.

Use of these recommendations in practice and their impact on quality of care for Muslim women has yet to be explored. Religious practices in relation to stillbirth and neonatal deaths were not explored in this study, further exploration in this respect is needed to add to current recommendations.

Conclusion

The study recommendations promote a woman-centred approach that takes in to account Muslim women’s specific needs as defined by them. It is hoped that these recommendations will facilitate conversations between Muslim women and HCPs that will help address the individual needs of Muslim women.