Contraceptive Beliefs and Practices of American Muslim Women

Introduction

The American Muslim population is estimated to total 3.45 million, with 60% between the ages of 18 and 39. ¹ This population is growing rapidly driven largely by higher fertility rates among Muslim Americans and continued migration of Muslims to the United States. ² Few studies have looked at the reproductive health care needs of self-identified Muslim American women. Shahawy et al. concluded that reversible methods of contraception are used by Muslims worldwide and are considered permissible within the Islamic faith, but irreversible forms of contraception are considered more controversial when used outside the scope of medical necessity. ³

More recently, Budhwani et al. found that 79.5% of Muslim women in a convenience sample obtained online reported using any form of contraception; over 60% reported ever using contraceptive pills or condoms, 32% coitus interruptus, and 16% an intrauterine device (IUD). ⁴ Recent studies highlight health care providers' lack of understanding about this population's customs and beliefs in the United States. ^3,5,6 These authors noted that there is an increasing need for clinicians to have a better understanding of what self-identified Muslim women believe about contraception to enable them to provide culturally appropriate care to these women. ^3,5

A review of writings from religious experts reveals that Islam encourages procreation, but that contraceptive methods, such as coitus interruptus, are known to have been practiced by early Muslims. ^7,8 Passages from the Quran encourage breastfeeding for a 2-year duration, historically leading Muslim societies to accept lactational amenorrhea as a method of child spacing. ^9,10 Writings of Muslim jurists make it clear that Islam allows for the use of reversible methods of contraception, including oral contraceptives, condoms, coitus interruptus, emergency contraception, injections, subdermal implants, IUDs, spermicides, and diaphragms. ^3,7,11 Muslim scholars consider these methods acceptable for medical treatment (i.e., treatment of menstrual-related conditions), family planning, and regulating menses to perform religious rituals (i.e., fasting in the month of Ramadan or enabling women to perform certain aspects of the Hajj pilgrimage, from which Muslim women on their menses are excluded). ⁷ However, Muslim jurists do explain that Muslim women should not feel pressured to use these contraceptive methods for the purpose of performing these religious rituals. A woman's decision regarding whether to use these methods to perform these rituals is hers to make, and her adherence to the faith is not lessened if she chooses not to use these methods, nor is it increased if she does. Muslim jurists write that Islam emphasizes the spiritual equality of men and women regardless of whether a woman is able to perform these religious rituals or not because of menses. Use of irreversible methods, such as vasectomy or tubal ligation, are considered by most Muslim jurists to be justified only in situations of medical necessity and are to be considered on a case by case basis. ⁷ It should be noted that Muslim jurists preface these statements with the conditions that the contraceptive method will not cause more harm than benefit and that a Muslim woman should be under the care of a qualified health care provider. ⁷

Despite the writings of Muslim jurists making it clear that Islam allows for contraception, little is known about American Muslim women's personal beliefs about the appropriateness of different contraceptive methods and whether their actions reflect those beliefs. Estimated utilization rates in Muslim majority countries range from 22.9% in Afghanistan to 77.4% in Iran. ¹² The range of these rates suggests that there are numerous cultural, socioeconomic, and religious factors at play that affect how Muslim women perceive and utilize contraception. ⁴ The study of Budhwani et al. is the only one to date to look at American Muslim women's contraceptive utilization patterns, and it suggests that these patterns share certain similarities with both American women in general and with disadvantaged racial and ethnic minority groups in the United States. ⁴

Our group has been interested in past and present contraceptive use by Muslim women, and it also wanted to explore the question whether Muslim women thought their contraceptive use was consonant with or in conflict with the tenants of their faith. For example, many Catholic women who utilize modern methods of contraception are aware that this is in conflict with Church doctrine. ¹³ This dissonance can affect the way clinicians' approach contraceptive counseling and the long-term concerns users may experience.

To enable clinicians to better serve their Muslim patients, this article attempts to provide insight into Muslim women's beliefs about the appropriateness of contraception within their religion as well as their personal practices. Surveys were conducted online and in-person at Southern California mosques asking female congregants about their perceptions of Islam's stance on birth control, their own personal usage of contraception, and also their potential for future contraceptive use.

Materials and Methods

Both the John F. Wolf Human Subjects Committee and the Research Committee at the Los Angeles Biomedical Research Institute approved this project on an exempt basis because the study posed no more than minimal risk to participants and no personal identifying information was to be collected (Project No. 30638-01). Before initiation of the study, the survey tool was beta-tested in different settings to ensure understandability of questions and reproducibility of responses (see Appendix A1). Differently phrased redundant questions provided internal validation. Since the study subjects could potentially constitute a vulnerable population, the authors approached four major mosques in Southern California and obtained letters of support from each of them to conduct this project with their members. Only English speaking, nonpregnant women, 18 years of age or older, were included in the study.

Permission was given to approach female congregants individually at all four mosques to recruit for the study. To reach women who were not in attendance at the time of the in-person surveys, community electronic mailing lists were provided by three of the four participating mosques. The electronic listservs were for entire mosque membership, and only one email was sent out to each list. Both online and in person, the purpose of the survey was explained to potential participants; they were given an overview of the types of questions that would be asked. They were reassured that study participation was entirely voluntary, that they could withdraw at any time, and could decline to answer any of the questions. They were also informed that their responses would be anonymous and confidential.

The survey included a total of 30 questions, but this article focuses on 16 questions that related directly to contraceptive beliefs and personal utilization (Appendix 1). Demographic information that was collected by this survey included age group, descent, educational level, annual household income group, relationship status, and number of previous pregnancies. Participants were asked if they had been born and had spent the majority of their lives in the United States (US) or were more recent immigrants, whether they had been Muslim from birth or had converted into the faith, and with which sect of Islam they identified (i.e., Sunni, Shi'a, or other). In addition, women were asked if they chose to routinely wear any garments that visibly identified them as Muslim (i.e., headscarf).

The survey then queried participants on whether they believed Islam allowed for the use of birth control to prevent pregnancy, to treat menstrual-related conditions (e.g., heavy bleeding), or to regulate menstrual bleeding to enable them to perform religious rituals (i.e., delaying or suppressing menses to allow women to pray, fast, or perform the complete Hajj pilgrimage). Following this, participants were asked to identify all methods of contraception that they had ever used, the methods they would be comfortable trying now or in the future, and the methods which they believed Islam did not allow women to use.

Respondents were not limited in the number of responses they could select in the multiple-choice questions. All surveys were entered into Microsoft Excel. Descriptive statistics included counts and percentages calculated for nominal data using Microsoft Excel. With the knowledge that the survey tool would yield detailed information about each of the demographic variables, we planned to combine some of the options into comparably sized subgroups for each independent variable used in our analysis (age, descent, income, gravidity etc). The chi-square or Fisher's exact test was used to detect statistical differences between these subgroups. In the calculation of percentages, denominators were adjusted to reflect the number of women who responded. A two-tailed p value of <0.05 was considered statistically significant.

Results

From June 2017 to November 2017, 200 women were approached in-person at the 4 participating southern California mosques and 176 women (88%) agreed to participate in the study. An additional 102 responses were obtained from the online invitation, producing a total convenience sample of 278 women. Because the electronic mailing lists provided by the mosques were for all members (male and female), it is not possible to know how many women viewed the survey. Therefore, we cannot calculate a response rate for this portion of the study. Two respondents were not Muslim, so 276 responses formed the study population. Two hundred forty-six (89.1%) of the participants responded to every one of the 16 survey questions. All 276 participants reported their contraceptive beliefs, and 251 participants (90.6%) reported which methods they had ever used or would be comfortable trying in the future.

Respondents were predominantly younger than 35 years of age (64.4%). The majority had a college degree (83%). Annual incomes generally exceeded $60,000 (62.7%). Nearly two-thirds (63%) reported being married. Three quarters (75.5%) identified themselves as being either of Middle Eastern or South Asian descent. Forty-three percent of respondents were immigrants, and 77.3% of them reported spending the majority of their lives in the US. Eighty percent were Muslim from birth and 82.5% identified with the Sunni sect. Seventy-five percent reported wearing the headscarf in public. Table 1 displays more detailed information about the demographics and religious practices of the study population.

Nearly four out of every five respondents (79.7%) believed that Islam did allow for the use of contraception for pregnancy prevention or pregnancy delay (Table 2). Slightly more (84.8%) answered that Islam allows for the use of contraception for treatment of menstrual-related medical conditions. However, only 64% stated that contraception was allowed for regulation of bleeding for religious rituals (Table 2). Respondents with greater than a college degree or with the highest income level were more likely to report that Islam allowed for contraception. Respondents who wore a headscarf were also more likely to believe that Islam allowed the use of contraceptives for both pregnancy prevention (82.7%) and regulation of bleeding for religious rituals (70.7%) than those who did not. Women who had converted to Islam were significantly less likely to believe contraception was allowed for either indication, compared to women born into the faith. Although these statistically significant differences were identified, Table 2 also demonstrates that in every subgroup, the majority of respondents believe that their religion approved of contraception for fertility control.

Among reproductive age participants (<50 years old, n = 247), nearly half believed that Islam allowed for the use of all forms of contraception (48.2%); 82.2% believed that all forms of reversible contraceptives were allowed. Over one third (35.2%) did not believe that permanent contraception was permitted; 18.6% thought that emergency contraceptives (EC) was prohibited; but less than 10% of participants believed that any other method was disallowed within Islam. Participants within this reproductive age group who wore a headscarf were more likely to believe permanent contraception was not permitted. Participants who converted to Islam were more likely to believe EC was not permitted within the faith. Compared with younger women, far fewer (34.5%) of women 50 years and older (n = 29) believed that Islam allowed the use of all forms of contraception, but like younger women, 75.9% believed that all reversible methods of contraception were allowed. Forty-five percent of older women did not believe that permanent contraception was permitted.

Over 96% of reproductive age sexually experienced women in the study reported ever using any contraceptive method in her lifetime. Table 3 shows the rates of lifetime use by contraceptive methods for reproductive age, sexually experienced survey participants as well as methods these participants would be comfortable trying now or in the future. The most commonly ever-used methods included oral contraceptive pills (72.5%) and male condoms (68.9%), followed by coitus interruptus (39.9%), IUDs (21.2%), and calendar rhythm method (21.2%). Subgroup analysis yielded few differences. Currently married participants and those who reported ever being pregnant had significantly higher rates of ever having used any of those methods. Immigrant women were more likely to use IUDs than native born women. The methods participants would be most comfortable using now or in the future were similar to the most commonly ever-used methods.

Discussion

Hasnain et al. found that 93.8% of Muslim American subjects reported that their health care provider did not understand their religious or cultural needs, and that 83.3% of providers reported encountering challenges when providing care to Muslim women. ⁵ In this context, American clinicians who are not familiar with practices accepted by the Muslim faith may be unaware of the beliefs of their individual Muslim female patients. Ninety-three percent of those surveyed in our study believed that all reversible methods were acceptable in Islam, which is consistent with what earlier surveys conducted in Muslim majority countries have found. ^{14 –16} Fewer than half of our study participants (48.2%) believed that all methods were allowed. This lower number reflects the fact that over a third (35.2%) believe that permanent contraception was not permitted. Sterilization's “permanent” aspect has limited its endorsement by some Muslim scholars to cases of medical necessity (i.e., to prevent harm from subsequent pregnancies, or if infertility results from a necessary treatment), which may explain why participants were less likely to believe in its acceptability. ^3,7,17

Higher education, greater income, wearing a headscarf, and being born into the faith were all statistically significant factors associated with the belief that contraception was acceptable within Islam for family planning purposes. Importantly, however, even among women in the lowest income group, the vast majority (70.9%) agreed that contraception was allowed. Similarly, virtually the same percentage of women with the lowest educational achievement stated that contraception was allowed. Sixty-seven percent of converts to the faith accepted contraceptives for family planning.

Beliefs about the acceptability of a method from a religious perspective may not translate into personal use in the past or the future because many other factors may influence that selection. However, when women in our study reported personal past method use and anticipated what methods they might consider using in the future, their patterns were reasonably similar to contraceptive use patterns reported in national surveys for all American women as well as for Catholic and Protestant women. ^10,13,18 Just as a large majority of sexually experienced American women, who report a religious affiliation, use highly effective contraceptive methods, the reproductive age sexually experienced women in our survey reported having used either an IUD, implant, sterilization, the pill, or other hormonal method. ¹³ In addition, 71.8% reported that they would be comfortable trying these methods now or in the future. Table 3 demonstrates the similarities and subtle differences between the contraceptive usage experiences of this study population and that of the general U.S. population as well. ¹⁰ U.S. women overall tend to rely more on injectables and male or female permanent contraception, while the women surveyed were more likely to use or be interested in fertility awareness and IUDs. ^19,20 The greater popularity of IUDs in our group may be driven by other influences. We found that rates of IUD use and acceptability were higher among immigrant subjects than native born subjects in this study (p = 0.022). ²¹ Also, IUDs may possibly be used by these women in lieu of permanent contraception.

Our findings about contraceptive use complement those of Budhwani et al. ⁴ These authors also studied a highly educated, high-income sample of reproductive age sexually active Muslim women and both studies found high rates of lifetime contraceptive use. ⁴ They also reported similar rates of use of oral contraceptives, condoms, and coitus interruptus. ⁴ While they did not find considerable differences in contraceptive use between income or educational levels, they reported that Muslims who identified as Shi'a was associated with greater odds of using only oral contraceptive pills relative to Sunni respondents. ⁴ Our study did not show any considerable differences between income, education, or sect with respect to any form of contraceptive method surveyed. Our data showed stronger interest in IUDs. We established that contrary to some other religions, women in the Muslim faith do not believe that they are in conflict with their religion when they seek to control their fertility.

As with many American women of other religious faiths, 17.3% of participants did not believe that EC was allowed within Islam. Interestingly, a comparable number of participants (16.1%) reported ever-using EC themselves. Given that the vast majority of Muslim jurists permit oral emergency contraception, it is unclear why some question the Islamic legality of this method. Again, nonreligious factors may be influencing these beliefs. ⁷

Over 80% of our respondents believed that their religion allowed for the use of contraception for pregnancy prevention and medical treatment, however, a significantly smaller majority believed in its use for menstrual regulation for religious rituals. This was surprising given the common request by female Muslim patients globally for contraceptive methods to delay menses for religious rituals, such as the Hajj pilgrimage to Mecca. ²¹ This may represent a potential area of clarification and education for American Muslim women.

There are several limitations to the study. While this study included a diverse group of immigrant and native-born women with different parities, different religious practices, and a wide range of ages, it oversampled highly educated, wealthy, English-speaking Muslim women from a limited geographical region. Respondents were purposely recruited from Muslim organizations to assess religious practices and beliefs, which introduced a selection bias. While a reliance on bivariate statistics also limits our findings, our purpose was to obtain an overall sense of the perceptions and contraceptive practices of the American Muslim women surveyed. We found that across all demographic subgroups analyzed, there was little variation in both perceptions and utilization rates. Our findings may not be generalizable to the larger American Muslim population, particularly those who are indigent, have low literacy, or are non-English speaking. Despite these limitations, our study findings regarding contraception ever-use rates were similar to a recently published survey of women from across the US and more than double the number of women surveyed about this topic. ⁴

Conclusion

Among religious American Muslim women, contraception is believed to be permissible within Islam with a preference for reversible over permanent methods. This study also suggests that Muslim women are not only comfortable using these methods for family planning and medical use, but to also regulate menstrual bleeding for religious rituals. Current standards for providing quality family planning services call for health care providers to counsel patients on all available methods. ²² Our study should provide clinicians confidence that they will not be violating widespread religious beliefs of their Muslim patients, especially when counseling about the use of reversible methods. Clinicians should be aware that permanent contraception may not be as generally accepted as an option. On an individual basis, patient centered counseling will further clarify what each woman's own personal beliefs and preferences are with respect to contraceptive methods.