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

Prayer

Muslims have an obligation to complete five daily prayers, performed at different times of the day. Prayers include physical movement—standing to face the South East (toward Macca), bowing and prostration.

A prayer space—The woman/partner may need to perform the prayer while waiting for their appointment or during their stay in hospital.

A washing facility—Muslims perform Wudu—a ritual washing in preparation for prayer.

Awareness—Muslims may want to perform a daily prayer.

Practical actions: Signposting—Become aware of the availability and location of a prayer room and an appropriate washing area within the Trust or organisation.

If not available;

Temporal prayer space – if possible provide a temporal quiet space for the prayer to be performed.

May provide a clean sheet for them to perform the prayer on.

Modesty and privacy

In Islamic ethics modesty is reflected in a Muslim’s speech, dress and conduct. Outward modesty is often reflected in how a Muslim woman dresses in the presence of other people or the opposite gender. This can vary between Muslim women, from wearing clothing that is not revealing to full covering including the head and sometimes the face.

Covering—may need support in limiting how much of her body is uncovered, during clinical examination, regular maternal scans, while wearing a theatre gown, or while being in hospital wards and during labour or while breastfeeding.

Preference for a female HCP—some Muslim women prefer not to be attended to or examined by a male HCP, or only if absolutely necessary. This includes male student trainees or male interpreters. Even in an emergency, some Muslim women may still refuse to be attended to by a male HCP.

Awareness—Muslim women may want to maintain modesty and limit body exposure e.g. during clinical examination. This can include covering certain body parts (including head and face) and/or being attended to by a female HCP.

Practical actions:

Provide resources – If possible, provide additional sheets, or stockings to cover legs or provide an extra gown, for example, during a maternal scan or in labour to support Muslim women to feel comfortable and not too exposed.

Flexibility: During the preparation for theatre, walking or getting to theatre, wearing a short hospital gown can be uncomfortable for some Muslim women. If possible, allow women to keep their headscarf or their overall long garment on until they get to theatre, removing this once in theatre room. Alternatively, provide an extra sheet/gown or stockings to cover legs.

Ask a woman if she prefers her curtains to be open or closed e.g. during visiting hours or while she is breastfeeding

Provide time for the women to cover- While in a private appointment, examination or labour room some Muslim women may have taken their headscarf or face veil off or removed certain clothing—exposing their body. Give time for women to replace garments, for example, a headscarf before moving them to a different room, opening bay curtains or allowing another HCP into the room.

Being informative – make the woman aware that she is going to be consulted or attended to by a male HCP. If possible, explore if the woman is comfortable and if she has other preferences. If a female HCP is preferred, check if this can be organised. If not, ensure that this is explained to the woman, especially, in an emergency situation- highlighting that the key objective at this time is her safety. This will help the woman make an informed decision.

Dietary considerations

It is common for Muslims to consume and accept what is considered lawful (HALAL) by Islamic teachings and to refrain from anything considered prohibited (HARAM). Main prohibited foodstuffs and liquids include Pork (and its by-products); animal fats and meat that has not been slaughtered according to Islamic teachings and alcohol. There are certain exceptions to these teachings that allow for animal-based medications or vaccine to be used e.g. if there is no other lawful option available and their usage is for the greater benefit of the person.

Note: not all Muslim women may consider this religious exception

Alternative options—Some Muslim women may reject certain medication or vaccines (e.g. Vitamin-K for the new-born) if they contain any unlawful substance.

Being informed: Muslim women expect to be informed of the content of medication prescribed.

Awareness—some Muslim women may require alternative options that adhere to their religious teaching.

Practical actions:

Record specific dietary requirement- explore with the woman any specific dietary requirement and their preferences if alternatives options are not available.

Flexibility with alternative options- e.g. when providing food, note that not all Muslim women will be happy with a HALAL option; some may prefer something else such as a vegetarian option.

Being aware- it is important to be knowledgeable about content of medication or vaccine provided (whether it contains any animal extracts within it). It is important that women are informed and are given a choice if another suitable option is available.

Note: this is also important for other women who may be vegetarians, vegans, Hindu, Jews and others with specific dietary requirements.

Provide possible alternative- if available provide possible alternatives e.g. medications that are suitable for vegetarians or vegans are often an appropriate alternative.

Fasting in the month of Ramadhan

It is common for Muslims to fast during the Islamic month of Ramadhan- often described as a community worship, it includes observing fast (no eating or drinking) from sunrise to sunset.

Note: There is a religious exception for a pregnant or breastfeeding woman who can choose not to observe fast during the month of Ramadhan but make up the fast at a different time of the year.

Open discussion—Some Muslim women who are pregnant or breastfeeding during the month of Ramadhan may attempt to fast. They may not want to miss out on the community fast and find motivation to engage in the fast with the rest of their family. Muslim woman may need to have a discussion with the HCP to help them make an informed decision.

Nutritional advice—may require nutritional advice to support them during the fast.

Awareness—some Muslim women may observe fast during the month of Ramadan.

Practical actions:

Ramadhan on the annual calendar – It is important to be aware of when the month of Ramadhan is.

Note: some Muslim women may not feel confident to mention their intention to fast.

Open discussion—Telling Muslim women not to fast can often inhibit discussion. It is important to explore fasting with the woman; allowing for discussion of her intentions during the month of Ramadhan, and how she is finding the fast if she is fasting.

Nutritional advice – Provide guidance to help a woman keep healthy during this period. Refer woman to nutritionist if necessary to help guide her during this period.

Quran Recitation

The recitation of the Quran is the first and most constant religious practice carried out by Muslim women throughout the stages of childbirth and during pregnancy—reflecting on the words of Allah and exposing their unborn child to hearing the word of Allah.

Aware of opportunity – a woman may not be aware if it is possible for her to play her Quran recitation during her stay in hospital, labour or in theatre.

Resource available—some women will use their own devices to play the Quran recitation (e.g. mobile phone) others may require a device.

Awareness—Be aware that some women may recite Quran during their stay in hospital including whilst in theatre or during labour.

Practical action:

Open discussion- explore with the woman any specific requirement during labour or in theatre e.g. explain to the woman that she has the option to play the recitation of the Quran during labour or in theatre (if possible).

Provide resource – If possible, provide a CD player or audio player to play their Quran recitation or provide headphones to help them use their own devices.

Birth position

Some Muslim women do not wish to be in a laying down position during labour– preferring instead to imitate Maryam (Mary the mother of Jesus) during her birth.

Support during labour – Requires HCPs awareness of women’s preference in order to support women during labour to get into the position they prefer.

Awareness—Discuss preference while exploring the birth plan with the woman, e.g. explore if there is anything specific they would like to practice and keep this on record.

Practical action:

Provide recourses – to support the woman during labour to get into the position she prefers (if safe).

Silent birth

Some Muslim women prefer the first word that their child hears at birth to be Allah’s name or the word of Allah.

Acknowledgment—some women prefer a moment of silent at the point of birth, so that they can mention Allah’s name for the child to hear. If not silent, some women may call the word of Allah at birth slightly louder than the other voices in the room for it to be significant for the child to hear than the other voices.

Awareness and acknowledgment—some women prefer a moment of silent at the point of birth or request HCP to speak quietly during the birth.

Practical actions:

Open discussion – while exploring the birth plan with the woman and her preferences during labour, check if she would like silent birth and record in notes.

Silent birth—if possible, during the birth try to minimise speaking as much as possible to give the chance for the mother and birth partner to speak the first words they want the child to hear. Women having caesarean section may request this too.

Adhan and Iqamah (call for prayer)

To whisper the Adhan to the new-born soon after birth. These words include the name of Allah the Creator and is followed by the Declaration of Faith: “There is no deity but Allah; Muhammad is the Messenger of Allah.”

It is customary for the father, or a respected member of the family or local community, to whisper the Adhan. The ceremony takes only a few minutes.

Acknowledgment – often the birth-partner (father or a mother figure) will do this practice, they may move to one side of the room with the baby to have a personal moment and some may wait until there is no interruption in the room. Some may wait for a member of the family or community with high status (such as grandfather) to carry out this practice.

Awareness—parents my request to have the baby and some privacy after birth to perform this practice.

Practical actions:

Provide some one-to-one time with the baby—if possible, give parents some one-to-one time with the baby following the birth. Silence may be required in the room to perform the Adhan.

Flexibility in access—restricting access to the delivery ward to partners can affect this practice.

Burial of placenta

Out of respect, women are encouraged to bury any separate part of the human body if possible.

Note: not all Muslim women would engage in this practice.

Being informed: Some Muslim women may not be aware of the options available with regard to taking their placenta home.

Guide and instructions: Some Muslim women may have the facility to bury their placenta and others may not. Women need information about how to safely transport and dispose of their placenta if they decide to take it home.

Awareness—some Muslim women may request to keep their placenta.

Note: some Muslim women may not feel confident to ask if they are not aware of this option.

Practical action:

Provide the option—make sure that all women are aware of this option. If this option is not available due to, for example, further tests being required on the placenta, women need to be informed.

Provide guidance – Provide guidance e.g. in a leaflet with appropriate and understandable language that can be read through with the woman to ensure that she understands the instructions.

Breastfeeding

It is religiously recommended for a woman to breastfeed for a period of 2 years.

Note: The majority of Muslim women will have the intention to breastfeed and may attempt breastfeeding but my struggle to continue if not supported.

Support initiation and continuing breastfeeding – Women need support in initiating and continue breastfeeding. This includes hands on and follow up support from breastfeeding support team.

Maintaining modesty – Some Muslim women may not feel confident to breastfeed in hospital wards, if for example, bay curtains are open or breastfeeding in front of other women.

Reassurance – some Muslim women are keen to fulfil their religious recommendation of breastfeeding, however, may struggle and lose confidence in their ability to breastfeed.

Awareness—that some Muslim women will be keen to breastfeed but may not be aware of some of the challenges they may face during this period.

Practical actions:

Open discussion – give time during pregnancy to explore the woman’s intention in breastfeeding and discuss what is important and any support she may require.

Support to initiating breastfeeding – offer hands on support to help women initiate breastfeeding. If in a situation where the new-born is away from the mother due to clinical reason (e.g. child needs to be in the incubator), explore possible options to support mother to breastfeed e.g. support women to express her breast milk.

Consent to donated breast milk—Muslim women may object to using donated breast milk due to strict religious implications e.g. if breast milk is ever shared with another child, then the two children are considered to be siblings and would not be allowed to marry each other when older. Women need to be consulted and well informed if donated breast milk is to be a suggested offer.

Support privacy during breastfeeding—some women may prefer their curtains to be closed while in a ward to help them breastfeed and a breastfeeding apron can support women maintain their modesty. Allow time for women to appropriately cover themselves while breastfeeding before allowing other HCPs or visitors into the room.

Continues checks—connect women to breast feeding support team to ensure that she is getting the support needed. Check with the woman during home visits and 6-week check if she requires further support

Provide reassurance – some women may find that breastfeeding is affecting them emotionally and mentally. It’s important that this is discussed with the woman and the best ways to support her are explored.

Male Circumcision

This is a religious obligation practiced by the majority, if not all Muslims, as it is for the Jewish community.

It is recommended that circumcision is performed within the first few weeks of life. Since this is not available on the NHS, some Muslims will seek out private clinics and some will travel to their home country to have this done. Other women prefer to delay circumcision until the child is of an age (over 1 years old) when the procedure may be available within some NHS Trusts.

Information about options available on the NHS – women may need guidance about NHS recommendations with regard to male circumcision.

Alternative options—difficulties in obtaining circumcision on the NHS means that it is usually performed in the private sector. Women may need advice on where is safe e.g. information about NHS accredited private clinics.

Awareness—that this is a practice that Muslim women are likely to implement.

Note: women may not feel confident to discuss this with HCPs due to the controversy around this practice.

Practical action:

Open discussion – Let the parent know that you are aware of this religious practice and have an open discuss about parents’ intentions and what support they need. This will include discussion about safety of the child, especially in infants that have clinical issues. For example, discuss delay of circumcision in jaundiced infants due to potential risk of prolonged bleeding, or in infants born with hypospadias where surgical opinion has been sought.

Provide information—be aware of the NHS recommendations around male circumcision to help guide parents to make informed decisions.

Signposting- if possible, get a list of NHS accredit private clinics that you can share with parents to support them pursue a safe option for their child.