Young mothers in Islamic contexts: Implications for social work and social development

Acceptability of early childbearing

Several studies have found higher rates of ‘teenage’ childbearing among Muslim young women in comparison to young women from other religions (Dulitha et al., 2013; Rahman, 2008). One interpretation of this has been that bearing children as an adolescent or young woman under 18 years in itself is not usually seen as a ‘problem’ from an Islamic perspective if it is in the context of marriage (Higginbottom et al., 2006; Rahman, 2008), which is near universal across the Muslim world (Hall, 2005). While there are Islamic contexts where marriage is not legal until a woman is at least 18 years (UNFPA, 2013b; UNICEF, 2009), there are also examples of where earlier marriage (under 16 or 18 years) is sanctioned and encouraged by Islamic leaders (Oxfam, 2008; Rahman, 2008; Sabbe et al., 2013). Indeed, the tension in Western centric definitions of childhood is predominately determined by age, whereas Muslim communities often take a subjective interpretation based on developmental capacity or reaching puberty (O’Leary and Squire, 2012). This discretion is recognised by virtue of the fact that under classical Muslim law, marriage of a girl who has attained puberty can be interpreted as being valid (Rahman, 2008; Sabbe et al., 2013). Yet, childbearing which occurs outside the context of marriage is usually considered a significant social and moral problem in Islamic communities (Ghani et al., 2014; Jamaludin et al., 2013; Nordin et al., 2012) and is illegal in some Muslim-majority contexts.

Dixit et al. (2012) also found a positive association between being a Muslim and higher levels of unwanted pregnancy in India, which has also been demonstrated in other studies across South East Asia (Chacko, 2001; De Silva, 1991). Faye et al. (2013) suggest that there are few studies on married Muslim women regarding unwanted or unintended pregnancy because of pro-natal attitudes. It is therefore socially unacceptable for women not to start childbearing immediately after marriage. It is also difficult to access women who have conceived out of wedlock. Wickstrom et al. (2006) also report it is hard to gain cooperation from senior Islamic leaders on family planning in Senegal. In many settings, Muslim families have more children and are consistently less likely to be using contraception (Dixit et al., 2012). It should be noted though that Karim (1997, 2005) and Hall (2005) caution against making assumptions about Islamic trends of fertility, suggesting there is not a ‘typical’ pattern of reproductive behaviour which would be considered ‘Islamic’ when considering global trends. At a country level, however, certain trends have been observed by religious and political affiliation. For example, Yemen has the lowest rate of contraception use in the Middle East and North Africa because many women believe that Islam prohibits this (Roudi-Fahimi, 2004). Whereas in Egypt and Iran, women have high rates of contraception use because governments actively promote family planning through the use of Fatwas and public education (Roudi-Fahimi, 2004).

Impact on maternal and infant health

A significant study by Bhalotra et al. (2009) found that while the socio-economic status of Indian Muslims is, on average, considerably lower than that of upper-caste Hindus, Muslims nevertheless have for decades exhibited substantially higher child survival rates. A decomposition of the survival differential confirms that some compositional effects favour Muslims but that, overall, differences in characteristics and especially the Muslim deficit in parental education predict a Muslim disadvantage (Bhalotra et al., 2009). Potential explanations include stronger social networks (due to stronger kinship, marriage culture and their minority status in India), their lower son preference and high levels of personal hygiene due to religious practices. According to Bhalotra et al. (2009), the findings supplement a growing literature on the role of religion and culture in understanding health outcomes. Elsewhere, though, Demissie et al. (2009) found that in Ethiopia the prevalence of subclinical vitamin A deficiency was significantly higher among Muslim children than among Christian children – which has also been found in other studies they cite. Although they did not collect socio-economic data which may explain the difference, they suggest that it may also be due to large family size in Muslim household, education of the mother, vaccination status of the children, parity levels of the mothers and awareness of vitamin A.

Dulitha et al. (2013) also found that belonging to the ethnic group ‘Muslim’ and ‘practising Islam’ emerged as risk factors for teenage pregnancy in Sri Lanka, but there is no discussion about why this might be the case. Available literature can be both contradictory and unspecific on the role of religion on child and maternal health outcomes. While some studies analysing trends based on large-scale data collection on reproductive health find a significant difference in health outcomes by religion (particularly in countries where there are groups of women from different religions large enough to offer a comparative perspective like India and Nigeria), many studies are unclear as to why these differences by religion occur nor do they go on to discuss the role of religious processes in interventions (Faye et al., 2013; Marroun et al., 2008; Singh et al., 2012). Moreover, the role of religion in promoting positive child and maternal health outcomes within social programmes is underdeveloped.

It is usually assumed that Muslim women will breastfeed for longer due to Islamic texts which encourage women to breastfeed for up to 2 years (Karim, 2005; Unnithan-Kumar, 1999). Bhalotra et al. (2009) highlighted that Muslim women in India tend to put the baby to the breast sooner after birth than women from other religions. Yet, in regards to breastfeeding in Bangladesh, Akter and Rahman (2010) found (using Demographic and Health Survey (DHS) data and Cox regression analysis) that being a Muslim was significantly associated with lower durations of breastfeeding. These data call into question some of the widespread assumptions made about the breastfeeding of Muslim women and the role of age and education. These contradictory results clearly highlight the need for further research.

Accessing maternal and child health care

Regularly accessing appropriate antenatal and postnatal care is widely considered as crucial for reducing child and maternal mortality and morbidity. Poor access to these services can exacerbate the challenges for young mothers who may become isolated within large families once they become pregnant. A number of articles have found that religion is a significant factor impacting on important health and social behaviours regarding maternal and child health such as attending antenatal appointments or ensuring adequate nutrition (Chakrabarti and Chaudhuri, 2007; Pallikadavath et al., 2004). Using the National Family Health Survey data 1998/1999 in India, Chakrabarti and Chaudhuri (2007) found that women residing in a household where the head is ‘Muslim’ were less likely to deliver in a public or private facility and more likely to deliver at home which is thought to increase maternal and child health risks. More recently, using the data from the third wave of the National Family Health Survey (2005–2006) in India, Singh et al. (2012) found that nearly half of the adolescent women from other religions utilised safe delivery care, while the corresponding figure for Muslim women was reported to be 37 percent. The utilisation of postnatal care and the likelihood of a safe delivery were all found to be significantly lower among Muslim women when compared to Hindu or other religious groups. Similarly, Bhalotra et al. (2010) also found that Muslim women gave birth outside medical facilities more often than their Hindu counterparts; Dharmalingam (2002) found that Muslim women in Kerala were less likely to deliver a baby in a heath care institution than Hindu women. While the literature indicates that Islamic influences might be playing a role in reducing access to maternal health care service, the ‘Islamic influence’ is not necessarily uniform across countries or regions within a country. In some regions of India, for example, women from Muslim households were significantly more likely to access antenatal care, while in other regions, it was women from Hindu households who were significantly more likely to access this health care support (Pallikadavath et al., 2004). These kinds of differences are rarely understood through the sole use of quantitative data sources (Dharmalingam, 2002).

Levels of autonomy

One reason often used to explain why Muslim women are less prone to use formal care services during pregnancy is the restrictions often placed on their freedom of movement and overall lower levels of autonomy (Chakrabarti and Chaudhuri, 2007; Dixit et al., 2012). Adhikari et al. (2009), for example, suggest that one reason why Muslim women in Nepal have higher rates of unintended pregnancy than Hindu women is because Islam restricts women’s activities in ways that other religions do not. Hennink et al. (1999) also found that girls of Muslim and Sikh faith report more social restrictions and limited involvement in relationships (before marriage) than their peers of Hindu faith. In addition, Hazarika (2011) suggests that the ‘purdah’, a physical segregation of the sexes which can occur in some Muslim contexts, and the requirement for women to cover their bodies may be contributing to the low utilisation of safe delivery care in some contexts. Within societies where the principal values are based on strong religious and cultural traditions, adolescents may withdraw from view due to fear of rejection and judgement (Ghani et al., 2014). Consequently, Unnithan-Kumar (1999) believes that reproductive health practice among Muslim women in India has not been well-researched due to the widespread notion regarding the tight Islamic control over sexual behaviour and the sanctions against contraceptive use. Yet Pallikadavath (2004), who used the data to compare access to antenatal care across certain regions in India, found that in some areas Muslim women were more likely than others to receive components of antenatal care despite the stereotype of Muslim women being secluded from care.

Morality

A number of other studies highlight the moral concern which is growing in some parts of the Muslim world regarding youth sexuality and premarital sex (Harding, 2008; Nordin et al., 2012). Islam strongly upholds the chastity and the modesty of Muslim women, and very often there are rules and strict guidelines which mediate relationships between men and women (Nordin et al., 2012). Sexual activity which occurs outside the confines of marriage is therefore often attributed to a lack of awareness of Islam and faith (Rahman, 2008). In response to this, Ghani et al. (2014) used the Moral Values Inventory for Muslim Adolescences (MVIMA) and Coping Strategy Inventory to examine the relationship between Islamic moral values and the coping strategies used by female adolescents involved in premarital sex. The tools were distributed to 238 ‘inmates’ from four government rehabilitation centres in Malaysia based on the assumption that the two main contributing factors to premarital pregnancy include the lack of moral values and coping strategies. They found that all respondents had moderate levels of moral values which were attributed to the Islamic religious classes they had received in the rehabilitation centres, and recommendations of the study included the need for ‘moral’ education to decrease premarital sex. Islamic religious teachings are therefore considered a protective factor against premarital sex along with activities which increase assertiveness, positive self-respect and levels of self-esteem. In Islam, it is believed that spirituality leads to moral development (Ghani et al., 2014). Nordin et al. (2012) also found that unmarried mothers living in a shelter home in Malaysia benefited from the religiously and spiritually grounded strategies used which supported the emotional and the spiritual needs of the unwed mothers staying there.

Inclusion of religion in interventions

There are a number of examples across the literature where Islamic perspectives have been drawn on to promote gender empowerment and discussions of sexual and reproductive health or family planning (Ghani et al., 2014; Nordin et al., 2012). For example, Sciortino et al. (1996) document how the Indonesian Society for Pesantren and Community Development links issues of social justice, gender and reproductive health within Islamic jurisprudence and runs workshops for women who are active in Islamic boarding schools in rural Java and Madura, including on pregnancy and childrearing, maternal mortality, clandestine abortion, sexual relations and HIV/AIDS. Save the Children (2004) also draws attention to marriage counsellors in Indonesia from Islamic and secular institutions who were trained to give information about family planning along with other health and relationship advice. Islamic law experts were also key in raising awareness of Morocco’s new family code which raised the minimum age of marriage for girls from 15 to 18 years (Save the Children, 2004). In Uganda, The Islamic Medical Association of Uganda (IMAU) trained and supervised over 8000 religious leaders and their teams of volunteers to provide education on HIV/AIDS and spiritual support to those affected (UNAIDS, 1998).

While there are a few examples across the literature of sexual and reproductive health interventions which include religious leaders or teachings, there is little information about the extent to which Islamic perspectives are integrated into programme development. Nor does it appear that many formal evaluations have been published regarding such programmes and whether including an Islamic perspective or Islamic ‘processes’ makes a significant difference to outcomes for young mothers and their children, or what the associated challenges might be. Clearly, these are important knowledge gaps for social work and social development.

Targeted intervention with young Muslim mothers

It is clear that experiences of early childbearing are shaped by social processes influenced by religious, cultural and ethnic identities, and these need to be taken into account when working with young Muslim mothers in both Muslim-minority and Muslim-majority contexts (Faye et al., 2013; Ghani et al., 2014). Early childbearing in itself may not be seen as a ‘problem’ or ‘context of vulnerability’ in Muslim communities if it occurs within marriage and in fact may be expected. It is not clear from the literature how different communities perceive and understand the risks associated with early childbearing or how families might support the particular needs of mothers and babies. Islamic teachings suggest that primary responsibility for the care and protection of mothers and their children is that of the husband and family (Sada et al., 2005; UNICEF and Al-Azhar University, 2005). There is little discussion about the role young mothers play in securing their own care and protection and the types of negotiations which may be necessary to achieve this. As a result, it is likely that professionals working without a legal mandate for intervention will need to work alongside families to gain their trust and collaboration to jointly identify the risks and viable processes of protection. Professionals will need to carefully balance and negotiate the needs of the young woman and child with those of the husband and wider family (Authors own, 2014).

The sensitivities and complexities of early childbearing dramatically increase when conception occurs outside of marriage. Risks of rejection from the family, unsafe abortion or abandonment of the child dramatically increase because of a strong Islamic teaching that extramarital sex is forbidden (Ghani et al., 2014; Jamaludin et al., 2013; Nordin et al., 2012; Rahman, 2008). It is likely then that this group requires targeted intervention and support by social workers. In Malaysia, for example, young unmarried mothers are usually housed in rehabilitation centres or shelter homes and receive intervention to support their reintegration into society. Social workers in this context can play an important role as ‘advocate’ in family courts and during family negotiations. Young mothers in these contexts are particularly vulnerable because of their ‘undeserving’ and ‘immoral’ status. Social workers in this context need to carefully balance societies’ perceptions (and in some case criminalisation of pregnancy out of marriage) while supporting and protecting young women from harm and upholding their human rights.

It is widely accepted that access to antenatal, delivery and postnatal care can significantly decrease the risks of mortality and morbidity associated with early childbearing. It also appears that in some contexts women from Muslim families are less likely to access such support services than women from other religions (Chakrabarti and Chaudhuri, 2007; Dharmalingam, 2002; Pallikadavath et al., 2004; Singh et al., 2012). Even in the United Kingdom, Higginbottom et al. (2006) found that practitioners were concerned that young women of Muslim faith may be under-represented in accessing advice and support services for early childbearing. Social workers can play an important role, working alongside other health professionals, in supporting young women to access maternal health services during and after pregnancy, recognising that there may be complex religious, cultural and socio-economic reasons why accessing such services is difficult. It may be that services need to be adapted to increase accessibility and resources invested to support relational strategies and negotiation skills. Clearly, early childbearing has implications beyond maternal and child health, relating to women’s autonomy, human rights, relationships within the family and future livelihoods. Holistic needs assessments by professionals which draw on ecological models of risk and protection (Blum and Mmari, 2005) are essential to supporting young Muslim mothers.

Unpicking socio-economic impacts, and religious, cultural and indigenous influences

As illustrated above, the influence and integration of Islam on the lives of individuals, households, communities and countries is wide, complex and difficult to predict. Critically, it is often difficult to determine whether the influence of religion is mediated by other social and cultural factors or whether social factors are mediated by religion. It is critically important that the influence of socio-economic factors is elucidated when considering ways to help improve the outcomes of early childbearing. Mistry et al. (2009), for example, link the lower maternal health care utilisation among adolescent Muslim women to their lower socio-economic status. Although other studies have found differences by religion which are independent of socio-economic status and even challenge the dominance of socio-economic status as the overriding predictor of outcomes (Bhalotra et al., 2010; Mahmood and Ringheim, 1996; Miah, 1992; Nasir and Hinde, 2011), conflicting practices and a poor understanding of Islam across the world have resulted in a conflicted discourse about whether Islam has a positive or negative impact on health and social outcomes (Laird et al., 2007), resulting in potential structural inequalities in health care delivery to Muslim patients. Several studies which found a difference in health outcome by religion concluded that more in-depth studies were needed to explain the differences found (Bhalotra et al., 2010; Demissie et al., 2009; Filmer and Pritchett, 1997).

Islamic teachings and laws shape lives through individual and collectives belief systems, the media, social norms, attitudes, values and traditions, national and local legislation and governance, and active intervention by religious figures and organisations. However, the influence of Islam is also mediated by many other factors such as non-Islamic social norms, attitudes, values and traditions, socio-economic status and education. Early marriage, which is highly associated with Islamic communities, is also considered an economic strategy often used by the poor whatever their religious affiliation (Hall, 2005; James, 2010; Schuler et al., 2006). It is therefore difficult to predict the homogeneity of different communities of Muslims. Islamic teachings play their part within the context of political, social, economic and demographic setting of each country. Understanding the interaction of such factors for each family requires social workers to draw from theories and understandings of society from their professional training. Muslim leaders state it is important that social workers have a knowledge of Islamic practices when working with Muslim families (Authors own, 2014). They also highlight the importance of Muslim leaders having knowledge on the role of social workers (Hutchinson et al., 2015). Creating relationships and environments to facilitate this exchange of knowledge is a clear role for social workers. Creative ways which draw out tacit and cultural knowledge which may be difficult to identify and express are critical.

Social workers also need to be aware that Islam has been infused with different cultural practices all over the world, resulting in some of these practices being mistaken for Islamic injunctions, particularly in poorly educated communities (Hall, 2005; Yusuf, 2007). Different practices coming from diverse cultural contexts are integrated into Islamic practices and then considered Islamic. Purdah (female isolation) and female genital cutting are two such examples (Sada et al., 2005; Wall, 1998; Yoder et al., 2004). However, unpicking the religious and cultural overlap is not easy, nor does it change the occurrence of particular practices which might be considered harmful. Yet, in order for social workers to properly assess and support young mothers and their families, they need to have a better understanding of the beliefs, values and practices which impact the well-being of families. Unpicking where some of these beliefs and practices stem from may highlight new areas of action for social work research and practice which are outside the normal frameworks for intervention.

Use of local religious and cultural processes to strengthen the protective environment for young mothers and their children

Over the past decade, there has been an increasing recognition that professionals working in social development need to engage with religious influences requiring them to work alongside community and religious leaders, and many other stakeholders, to protect women and children during early childbearing (Hutchinson et al., 2015; Save the Children, 2004; Zahr and Hattar-Pollara, 1998). This is particularly pertinent in contexts where state structures are weak and the influence of religious and cultural processes dominates local norms, values and practices (O’Leary et al., 2015). Religious communities are invaluable partners for engaging and supporting young mothers, particularly when religious actors have developed trusted relationships with their communities and have strong links with the most vulnerable and disadvantaged (Religions for Peace and UNICEF, 2010; UNFPA, 2009; UNICEF, 2012).

Ghani et al. (2014) and Nordin et al. (2012) suggest that increased engagement with Islamic religious education by young women would lead to an increased moral identity and reduce levels of premarital sex. However, Utomo et al. (2014) found that those students who attended religious schools (Madrasah) rather than general schools in Indonesia were a lot less likely to understand the biological processes of pregnancy and conception, putting them at risk of unwanted pregnancy. The focus on moral and religious education is problematic because it emphasises individual deviance, responsibility and character and ignores many of the wider social and economic factors which contribute to the occurrence and experience of early childbearing. Moral judgements also tend to fuel views that replicate the notions of ‘deserving’ and ‘undeserving’. However, drawing on Islamic thought which locates individuals in families and communities (Authors own, 2014; Sada et al., 2005), similar to that of an ecological model, opens up opportunities for social workers to engage with family and community processes which seek to protect and support young Muslim mothers rather than pathologise them as a ‘problem’.

There are a number of ways that social workers could partner with religious leaders or draw on religious processes to enhance the protective environment for young mothers and their children, particularly in Muslim-majority contexts where state systems for health and social care are weak. These could include the following:

All of these processes have the potential to increase the well-being of young mothers. However, such initiatives require great sensitivity to ensure partnerships are transparent and constantly evaluated to reduce any unintended risks (Hutchinson et al., 2015). Social workers may not be comfortable with all of the views held and actions taken by religious leaders (and vice versa) in response to early childbearing, especially when it involves premarital pregnancy or pregnancy as a result of rape or incest. A critical role for social work is to counter such differences by creating partnerships where respectful dialogue can occur to build trust and understanding. In many rural and developing communities, it will not be possible to make sustainable changes to the human rights of young mothers without partnering with religious leaders.

Under Islam, it is primarily the responsibility of husbands and families to ensure young mothers receive and can access sufficient support during pregnancy. However, this is not always possible due to poverty, lack of information and lack of services. It is also important to remember that young Muslim women are not passive agents within families even if they live under some restrictions, and in some cases, they will be able to manipulate rules or resist them (Keefe, 2006). A key role for social work is to partner with families and communities to uphold their religious and cultural responsibilities through addressing social and structural barriers that prevent them from achieving these goals.

Practitioners and religious leaders therefore need to move away from narrowly focused interventions targeting girls’ behaviour and involve family members and wider social processes (UNICEF, 2013). This will require social workers to work in multi-disciplinary teams with health, education and social development practitioners, economists and policy-makers in response to early childbearing (UNICEF, 2013).