The Effect of Ramadan Fasting on Breastfeeding Practices of Muslim Women

Abstract

Introduction:

Many breastfeeding mothers fast during Ramadan month despite being exempted from fasting. This study aims to estimate the prevalence rate of Ramadan fasting during breastfeeding and detect its associated factors among Egyptian Muslim mothers.

Methods:

A cross-sectional study was conducted on 1,130 lactating mothers selected through a multistage stratified random sampling technique in Dakahlia Governorate, Egypt. The data were collected through a structured questionnaire including sociodemographic data, the Arabic Scale of Intrinsic Religiosity (ASIR), and data about breastfeeding and fasting practices during Ramadan. Binary logistic regression analysis was used to detect the significant predictors of fasting among lactating mothers.

Results:

Of 1,130 study participants, more than half (53.5%) were aged ≥27 years old and had secondary education (54.6%). About four in every five (83.7%) of them fasted during Ramadan. Secondary education (adjusted odds ratio [AOR] = 2.71, p ≤ 0.001), university and postgraduate education (AOR = 4.88, p ≤ 0.001), non-working (AOR = 1.88, p = 0.011), being in debt and just meeting routine expenses (AOR = 1.75, p = 0.007), having high intrinsic religiosity (AOR = 2.70, p ≤ 0.001), having infants aged 6 months and more (AOR = 2.60, p ≤ 0.001), giving prelacteal feeding (AOR = 2.56, p ≤ 0.001), giving supplements (AOR = 2.11, p ≤ 0.001), and breastfeeding on demand (AOR = 1.92, p = 0.01) were the significant predictors of the higher fasting rates among the lactating mothers.

Conclusion:

Fasting is a prevalent practice among breastfeeding mothers of infants during Ramadan. Ramadan fasting does not significantly influence maternal outcomes or infant weight. Therefore, it is advisable for lactating mothers to consult with healthcare professionals prior to deciding to fast during Ramadan.

Introduction

Breastfeeding is considered a religious practice in Arab culture. Muslim Arab women’s adherence to Islamic values may influence their breastfeeding practices. Islamic jurisprudence presumes that a mother should breastfeed her newborn for a minimum of 2 years and that newborns have an inherent right to breastfeed. According to reports, religious doctrines serve as significant motivators that encourage lactation practice.^1,2

During the holy month of Ramadan, Muslims around the world fast from dawn until dusk. As one of Islam’s five tenets, fasting from sunrise until sunset for 30 days consecutively during Ramadan is obligatory for all healthy adult Muslims once a year. Fasting is a practice among Muslims.^3,4 Ramadan fasting is not obligatory for those who are ill or traveling. However, understanding the exclusions for pregnant and breastfeeding women can be more challenging, as neither condition is typically considered a disease in isolation. It is common for Muslim mothers who are breastfeeding to struggle with conflicting feelings of obligation to their faith and their children.⁵

While some mothers find it difficult to breastfeed while fasting during Ramadan, others are able to do so without experiencing any major difficulties or negative effects. Because they are not sure if “rukhsa” (exemption from fasting during breastfeeding) is relevant to their circumstances, some women are reluctant to use it. A lack of research and understanding of this problem in clinical practice can hamper the support that some women seek from health care or lactation professionals as they navigate this.⁶

Infants benefit greatly from breastfeeding. Babies who are breastfed tend to have healthier physical, mental, and behavioral development as they grow older.^7,8 Babies breastfed by moms who fasted during Ramadan continued to grow normally throughout the holy month and into its aftermath.⁹ Fasting throughout Ramadan has no negative effect on birth weight, according to Glazier et al.¹⁰ Also, prior research has shown that healthy, well-nourished moms continue to have an adequate milk supply even when they cut back on calories for a short period of time while fasting.¹¹ A new Turkish study stated that the calorie and macronutrient content of breast milk are unaffected by mothers’ religious fasting.¹² On the contrary, some researchers suggest that fasting during Ramadan has an impact on circadian rhythms, leading to increased day time, sleep, reduced irritability, and improved attentiveness. Interactions and attachments with their mothers mostly influence a newborn’s development.¹³

Ertem et al.¹³ investigated the perspectives and routines of breastfeeding moms on Ramadan fasting. According to their research, mothers’ beliefs about the impact of fasting on breastfeeding influence the rates at which they fast during Ramadan. To research the impacts of Ramadan fasting and establish connections with Islamic teachings, child health care workers should be well-versed in cultural and religious phenomena. This will allow them to discover culturally and religiously relevant ways to counteract the potential negative effects on infants and children.

We should not evaluate the practice of fasting during Ramadan by breastfeeding women solely based on nutrition and feeding concerns only. Consideration of religious believes are of paramount importance. To our knowledge, some Muslim nations have conducted limited research on the effects of Ramadan fasting on breastfeeding. However, Egypt has not conducted any such study. The current study aimed to estimate the prevalence rate of Ramadan fasting during breastfeeding and its associated factors, as well as the experience of fasting while breastfeeding among Muslim mothers in Dakahlia Governorate of Egypt.

Methods

Study design and setting

A cross-sectional study was conducted in Dakahlia Governorate located in Northeast of Delta from May to June, 2024, within 2 months after Ramadan.

Study participants

Lactating mothers attended the urban and rural health offices in Dakahlia Governorate of Egypt during the time of the study.

Inclusion criteria

Lactating mothers who have apparently healthy infants, lactating mothers (whether exclusive or mixed) who have infants aged 2–12 months and are free from any medical or surgical health problems that prevent them from fasting during Ramadan while breastfeeding their infants.

Exclusion criteria

All the women who would not agree to participate in the study were excluded.

Sample size

The sample size was calculated online using the Open Epi program (https://www.openepi.com/SampleSize/SSPropor.htm). A previous study found that 57% of lactating mothers fast Ramadan while breastfeeding their infants.¹⁴ With confidence level 95%, precision of 0.05 and effect size of three (due to stratified sampling method). The sample size was required to be 1,130 of mothers with infants within the first year of age.

Sampling method

Dakahlia Governorate was stratified into urban and rural areas. A multistage stratified random sample was carried out to select four rural and four urban health offices providing vaccination services. These eight health offices were selected from 30, depending on high flow rate to cover target number within a short duration. Samples were distributed proportionally between the selected health offices according to the annual number of live births in each office. The lactating mothers were consecutively recruited in each health office during vaccination sessions within the first year of infants’ age.

Data collection approach

The data were collected using a predesigned face-to-face structured questionnaire. The questionnaire was constructed based on literature review^13–16 to collect the following four main data parts. The respondents took approximately 15–20 minutes to complete the questionnaires.

Study instruments

A predesigned structured interviewer‐administered questionnaire was used in the study. It included the following parts: First part included sociodemographic data e.g., (age in years, residence (rural, urban), education (illiterate, read and write, primary or preparatory, secondary, intermediate, university, postgraduate), occupation (nonworking/house wife, working), and economic status (in debt, just meet routine expenses, meet routine expenses and emergencies and able to save money), infant’s age in months, infant’s sex (male, female), infant’s weight for age (W/a) (normal weight, underweight, and overweight, which was measured based on standardized World Health Organization (WHO) Z score and percentile) and birth order (first, second, third, fourth, and more). The second part included the Arabic Scale of Intrinsic Religiosity (ASIR) that measures internal religiosity regardless of any given religion or denomination. The ASIR consisted of 15 statements to be answered with a five-point intensity scale, anchored by 1 (Strongly Disagree) and 5 (Strongly Agree). Based on the good psychometric properties of the ASIR, it was recommended to use it to assess intrinsic religiosity.¹⁷ Third part included data about breastfeeding practices (time of initiation [early within 1 hours, late (1–24 hours], giving prelacteal feeds, giving supplements, type of breastfeeding (exclusive or mixed), and breastfeeding frequency (fixed and on-demand). Fourth part included data about the fasting practices during Ramadan (observed fasting during breastfeeding, belief of fasting in better health [essential and optional], methods of repeating the fasting [refasting after weaning or giving fidya], and reasons of nonfasting [lactation, any medical or surgical problems, and others]).

Statistical analysis

Data were collected, coded, and analyzed using IBM SPSS version 26 (Armonk, NY: IBM Corp.). Quantitative data were presented as mean ± (SD). Qualitative data were summarized as number and percentage. The Chi-squared test was conducted for comparison between categorical variables. Crude odds ratios (COR) and their 95% confidence interval (CI) were calculated. Binary logistic regression analysis was used to detect the significant predictors of fasting of breast-feeding mothers. Adjusted odds ratios (AOR) and their 95% CIs were calculated. p Value ≤0.05 was considered statistically significant.

Ethical considerations

The proposal of the study was approved by the Institutional Review Board (IRB), Faculty of Nursing, Mansoura University (0587). Informed written consent was obtained from lactating mothers who participated in the study after ensuring confidentiality.

Results

Of 1,130 lactating mothers, majority were aged ≥27 years (53.5%), had secondary education (54.6%), were not working and housewives (82.6%), of rural residence (77.6%), were in debt and just met the routine expenses (75.6%), had high intrinsic religiosity (55%), had an infant aged 6 months and more (73.2%), had infants with normal weight for their age (87.5%), and had second birth order (43.1%) (Table 1).

Table 1.

Sociodemographic Characteristics of Study Participants (n = 1130)

Variables	N (%)
Age^a
<27	525 (46.5)
≥27	605 (53.5)
Education level
<Secondary	173 (15.3)
Secondary	617 (54.6)
University graduate/postgraduate degree	340 (30.1)
Occupation
Nonworking/house wife	933 (82.6)
Working	197 (17.4)
Residence
Rural	877 (77.6)
Urban	253 (22.4)
Economic status
In debt/just meeting routine expenses	854 (75.6)
Meet routine expenses and emergencies/able to save	276 (24.4)
Intrinsic religiosity level^a
Low (<66)	508 (45)
High (≥66)	622 (55)
Infant’s age (months):
<6	303 (26.8)
≥6	827 (73.2)
Infant’s sex:
Male	620 (54.9)
Female	510 (45.1)
Infant’s W/a
Normal weight	989 (87.5)
Underweight/overweight	141 (12.5)
Birth order
First	335 (29.6)
Second	487 (43.1)
Third and more	308 (27.3)

Based on median, W/a: weight for age.

Regarding the breastfeeding practices, the majority of mothers initiated breastfeeding late (67%), gave prelacteal feeding (54.5%), gave supplements to their infants (68.6%), engaged in mixed breastfeeding (73.8%), and fed their infants on demand (89.1%). Regarding Ramadan fasting practices, the majority of them fasted (83.7%). Of the fasted ones, less than third (29.6%) fasted the whole month. 82.5% of them believed that fasting during Ramadan in better health is essential. More than half of them (53.5%) repeated the fasting by refasting after weaning. Among the nonfasting mothers, 60.9% refused fasting because of lactation (Table 2).

Table 2.

Breastfeeding and Fasting Practices of Study Participants (n = 1130)

Variables	N (%)
I. Breastfeeding practices:
Time of initiation	373 (33)
Early (within 1 hour of birth)	757 (67)
Late (1–24 hours)
Prelacteal feeding	616 (54.5)
Type of breastfeeding at interview
Exclusive	296 (26.2)
Mixed	834 (73.8)
Giving supplements to infant	775 (68.6)
Breastfeeding frequency at interview
On demand	1007 (89.1)
Fixed	123 (10.9)
II. Ramadan fasting practices:
Observed fasting during breastfeeding	946 (83.7)
No of days observed fast
Whole month	334 (29.6)
<30 days	612 (54.1)
Not fast	184 (16.3)
Belief of fasting during breastfeeding in better health
Essential (Fard)	932 (82.5)
Optional	198 (17.5)
If you cannot fast during Ramadan, how can you repeat it?
By refasting after weaning	604 (53.5)
By giving money or food to the poor (fidya)	526 (46.5)
Reason for not fasting during breastfeeding (n = 184)
Lactation	112 (60.9)
Any medical or surgical problems	46 (25)
Others^a	26 (14.1)

Others (feeling very weak, feeling more thirsty, feeling more hungry).

The bivariate analysis show that mothers had secondary (COR = 2.99, 95% CI [2.02–4.43], p ≤ 0.001), university and postgraduate education (COR = 3.31, 95% CI [2.11–5.19], p ≤ 0.001), were in debt and just met their routine expenses (COR = 2.27, 95% CI [1.62–3.17], p ≤ 0.001), were not working (COR = 1.95, 95% CI [1.35–2.83], p = 0.001), had high intrinsic religiosity (COR = 1.48, 95% CI [1.08–2.04], p ≤ 0.001), had infants aged ≥6 months (COR = 3.48, 95% CI [2.51–4.83], p ≤ 0.001), gave prelacteal feeding (COR = 3.31, 95% CI [2.36–4.65], p ≤ 0.001), gave supplements to their infants (COR = 2.89, 95% CI [2.09–3.99], p ≤ 0.001), gave mixed breastfeeding (COR = 1.59, 95% CI (1.14–2.24), p = 0.008, provided breastfeeding on demand (COR = 2.29, 95% CI [1.49–3.51], p ≤ 0.001), and believed that fasting is essential (COR = 1.81, 95% CI [1.24–2.63], p = 0.003) had significantly higher odds of fasting than others. However, age, residence, birth order, and the time of initiation were not significantly affected the fasting rates (p > 0.05) (Table 3).

Table 3.

Bivariate and Multivariate Analyses of Variables Affecting the Fasting Rates Among Study Participants During Breastfeeding (n = 1,130)

Variables	Total	Observed fasting	COR (95% CI)	AOR (95% CI)
Variables	Total	N (%)	and p value	and p value
Overall	1130	946 (83.7)
Age:
<27	525	430 (81.9)	(r)
≥27	605	516 (85.3)	1.31 (0.67–2.56)
Education level:
<Secondary	173	117 (67.6)	(r)	(r)
Secondary	617	532 (86.2)	2.99 (2.02–4.43)*	2.71 (1.73–4.25)^*
University graduate/postgraduate degree	340	297 (87.4)	3.31 (2.11–5.19)^*	4.88 (2.82–8.44)^*
Occupation:
Nonworking/housewife	933	798 (85.5)	1.95 (1.35–2.83)^**	1.88 (1.15–3.05)^***
Working	197	148 (75.1)	(r)	(r)
Residence:
Rural	877	737 (84)	1.10 (0.76–1.60)
Urban	253	209 (82.6)	(r)
Economic status:
In debt/just meeting routine expenses	854	741 (86.8)	2.27 (1.62–3.17)^*	1.75 (1.16–2.64)^**
Meet routine expenses and emergencies/able to save	276	205 (74.3)	(r)	(r)
Intrinsic religiosity level:
Low	508	410 (80.7)	(r)	(r)
High	622	536 (86.2)	1.48 (1.08–2.04)^*	2.70 (1.85–3.96)*
Age of infant (months):
<6	303	211 (69.6)	(r)	(r)
≥6	827	735 (88.9)	3.48 (2.51–4.83)^*	2.60 (1.76–3.83)^*
Birth order:
First	335	282 (84.2)	1.29 (0.86–1.94)
Second	487	416 (85.4)	1.41 (0.97–2.06)
Third and more	308	248 (80.5)	(r)
Time of initiation:
Early	373	301 (80.7)	(r)
Late	757	645 (85.2)	1.37 (0.99–1.90)
Prelacteal feeding:
Yes	616	560 (90.9)	3.31 (2.36–4.65)^*	2.56 (1.71–3.83)^*
No	514	386 (75.1)	(r)	(r)
Giving supplements to infant:
Yes	775	687 (88.6)	2.89 (2.09–3.99)^*	2.11 (1.44–3.11)^*
No	355	259 (73)	(r)	(r)
Type of breastfeeding:
Exclusive	296	233 (78.7)	(r)
Mixed	834	713 (85.5)	1.59 (1.14–2.24)^*
Breastfeeding frequency:
On demand	1007	858 (85.2)	2.29 (1.49–3.51)^*	1.92 (1.16–3.17)^***
Fixed	123	88 (71.5)	(r)
Belief of fasting in better health
Essential	932 (82.5)	795 (85.3)	1.81 (1.24–2.63)^**
Optional	198 (17.5)	151 (76.3)	(r)

^*p ≤ 0.001; ^**p ≤ 0.01; ^***p ≤ 0.05.

COR, crude odds ratio; AOR, adjusted odds ratio, % correctly predicted = 84.4%.

Multivariate analysis shows that secondary education (AOR = 2.71, 95% CI [1.73–4.25], p ≤ 0.001), university and postgraduate education (AOR = 4.88, 95% CI [2.82–8.44], p ≤ 0.001), nonworking (AOR = 1.88, 95% CI [1.15–3.05], p = 0.011), having debt and just meeting their routine expenses (AOR = 1.75, 95% CI [1.16–2.64], p = 0.007), having high intrinsic religiosity (AOR = 2.70, 95% CI [1.85–3.96], p ≤ 0.001), having infants aged 6 months and more (AOR = 2.60, 95% CI [1.76–3.83], p ≤ 0.001), giving prelacteal feeding (AOR = 2.56, 95% CI [1.71–3.83], p ≤ 0.001), giving supplements (AOR = 2.11, 95% CI [1.44–3.11], p ≤ 0.001), and providing breastfeeding on demand (AOR = 1.92, 95% CI [1.16–3.17], p = 0.01) were the significant predictors of the higher fasting rates among the lactating mothers (Table 3).

Regarding the effects of Ramadan fasting on maternal outcomes, only 0.2% of fasted mothers reported adverse maternal effects such as dehydration and a decrease in milk production with no statistically significant difference. Moreover, there was no statistically significant difference between weight for age of infants and fasting (p = 0.144) (Results are not mentioned in the tables).

Discussion

Muslim women face several barriers to following Islamic pregnancy and breastfeeding precepts, and the Quran does not exclude breastfeeding moms from Ramadan fasting.⁶ The Quran says: “There is a reward for anyone who can perform it with difficulty.”⁴ Fasting during Ramadan has an impact on billions of Muslims and doctors.

The present study found that the majority of breastfeeding mothers fasted during Ramadan month (83.7%). Similarly, previous studies conducted in Saudi Arabia (89.9%)¹⁶ and in Pakistan (82.2%)¹⁵ found that most of lactating mothers fasted during Ramadan month. This could be explained by the fact that many Muslim females who are breastfeeding prefer fasting in Ramadan for social and spiritual reasons, as it is more challenging to fast solely later when they have to compensate for missing days.^18,19 On the contrary, this current prevalence of fasting is higher compared with studies done in Ankara, Turkey (52%),¹³ Aydin, Turkey (50%),²⁰ Lahore, Pakistan (57%),¹⁴ and Jimma town, Ethiopia (67.8%).²¹ The discrepancy might be due to the difference in sample size used, culture, or spiritual beliefs in the study setting.

The current study found that 82.5% of mothers believed that fasting during Ramadan in better health is essential. Consistent with our results, a previous study done in Pakistan¹⁴ found that 87% of the lactating mothers had knowledge about religious relaxation. Another Pakistani research found that 76% of women considered fasting in Ramadan as compulsory.¹⁵ The possible explanation could be that mothers might have strong religious beliefs.

In agreement with our results, a previous Pakistani study¹⁴ found that the majority of mothers refused the fasting because of lactation. This finding revealed the fact that most lactating mothers know that Islam gives relaxation to the lactating mother. However, another previous Pakistani study¹⁵ contradicted with our findings and found that the main reason of women for not fasting was feelings of weakness, feeling hungry, and feeling thirsty. Moreover, the current study showed that only two lactating moms experienced dehydration and a decrease of breast milk production. This finding was supported by a previous Turkish research¹³ that found that 22% of breastfeeding mothers declared a decrease in their breast milk production. The extended days and high temperatures in the summer make fasting more challenging than in the winter.⁴ During the warmest and longest fasting days of Ramadan, even individuals who are in excellent health find it difficult to fast. In these days, breastfeeding mothers are at a higher risk of dehydration due to the prohibition of eating and drinking from dawn to dusk.²²

The bivariate and multivariate analyses of the current study found that moms with secondary, university, and postgraduate education were significantly more likely to fast than counterparts. This might be explained by the fact that highly educated mothers might know that fasting does not affect their health or their babies despite the flexibility rules of Islam exempting them from fasting. In contrast to our findings, a previous Turkish study¹³ found that primary education was a significant variable in bivariate analysis only. This difference might be explained by the different sample size calculated and knowledge level of mothers about Islamic rules during lactation.

Moreover, the bivariate and multivariate analyses of the current study found that nonworking mothers had significantly higher odds of fasting than working ones. This finding could be explained by the fact that housewives and nonworking mothers were far from the stress of work that needs concentration and high performance during day time, which encourages them to fast compared with working mothers. Only a previous study²¹ found that maternal occupation was not a statistically significant variable in both bivariate and multivariate analyses.

In addition, our study is the first to demonstrate that mothers who were in debt and just meeting their routine expenses were significantly more likely to affect and predict higher fasting rates. This finding could be attributed to having food restrictions, low knowledge about the flexible Islamic rules of fasting, poor knowledge on possible warning signs, and family recommendations that made them decide to fast. Moreover, our study found that mothers with high intrinsic religiosity were significantly more likely to fast than those had low intrinsic religiosity. No studies have discussed this issue until now. This finding could be explained by the strong religious effects in our Egyptian culture and lack of knowledge that Islam gives relaxation to lactating mothers.

The current finding showed that mothers had older infants aged ≥6 months and those engaged in mixed breastfeeding were more likely to fast during Ramadan. The supplementary foods and beverages offered to their infants, along with minimal daily breastfeeding, may encourage fasting behavior. Previous report²³ showed that if the infant is under 6 months and entirely reliant on breast milk, mothers should refrain from fasting. Another report²⁴ strongly recommends against fasting for mothers exclusively breastfeeding infants aged 0–6 months, citing heightened nutritional requirements. However, previous Turkish studies^13,20 indicated that mothers with infants aged 6 months or younger were more inclined to fast.

Consistent with our results, a previous Turkish study¹³ found that giving supplements significantly predicts higher fasting rates. This could be attributed to mothers’ knowledge about the importance of supplements in maintaining the quantity and quality of their breast milk during fasting that encourages them to fast during Ramadan month.

The present study found that prelacteal feeding was significantly associated with higher fasting rates among lactating mothers. Pérez-Escamilla et al.²⁵ found that the likelihood of exclusively breastfeeding or receiving any breast milk was lower among infants younger than 6 months who received prelacteal meals. This could explain that lactating mothers preferred to fast as their infants depended on formula during Ramadan.

Moreover, the current study found that no significant effect of Ramadan fasting on maternal adverse effects and infant’s weight. This supports the findings of Khoshdel et al.,¹⁸ who reported that Ramadan fasting had no significant impact on breast milk and infants’ growth. Also, some earlier studies revealed that fasting during Ramadan did not affect breast milk quality, volume, or newborn growth.^7,12,26

Child health care providers should include issues of fasting during Ramadan. They have to be knowledgeable about religious and cultural phenomena. They should inform lactating mothers about the flexibility rules of Islam during Ramadan fasting. Special consideration should be given to mothers who are at risk of fasting during Ramadan e.g., highly educated, nonworking, low-income families, having older infants, prelacteal feeding, giving supplements, and breastfeeding on demand. Also, they should research Ramadan fasting’s effects and connect with Islamic leaders to find religiously and culturally acceptable ways to mitigate their potential negative effects on infants and children.

Conclusion

This study found that the majority of Egyptian lactating mothers fasted during Ramadan month. Also, the majority of them believed that fasting is essential in better health. Many sociodemographic factors and levels of religiosity are associated with Ramadan fasting during breastfeeding. Also, Ramadan fasting has no significant effect on maternal outcomes and infant weight.

Study strengths and limitations

This is the first Arabic study to explore the prevalence rate of fasting during Ramadan and detect the predictors of fasting among Egyptian lactating mothers. However, the study has some limitations. First, the inherent limitation of the cross-sectional study to account for potential changes in maternal fasting during Ramadan for a longer period. Second, social desirability may overestimate fasting during breastfeeding, so that women appear to be more adherent to Islamic regulations.

Footnotes

Acknowledgments

The authors thank all the participants who voluntarily took part in this study.

Authors’ Contributions

Conceptualization and methodology: R.E., A.H.E., SH.M.M.A., and H.A. Writing original draft: SH.M.M.A. Data collection: R.E. and H.A. Data curation and analysis: SH.M.M.A. Writing and editing: SH.M.M.A. and A.H.E. All authors read and approved to publish the article.

Competing Interests

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

Funding Information

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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