Muslim women

• Muslim migrant women have different patterns of health seeking behaviour. Women from Asian, South Asian and Middle Eastern countries will expect that the onus is on GPs and LMCs to actively provide all necessary information to women in their care.
• Pregnancy and Parenting information may not be offered in home countries and Muslim women may not be aware of the information available to parents or understand the purpose.
• The presence of men in pregnancy and parenting classes contravenes religious beliefs and is a barrier to attending for some Muslim women. If women-only classes are available, it is important to offer this option.
• Muslim women require nutritional advice during pregnancy and breastfeeding that incorporates their halal religious and cultural requirements.
• Providing gender-matched professional interpreters and providing translated information on topics such as pregnancy, labour and breastfeeding is needed.
• Modesty is highly valued; women may request all female caregivers and will appreciate caregivers’ efforts to keep their body covered at all times. Protecting women’s modesty, even during examinations and for the birth of the baby will promote a trusting relationship between the woman and the health practitioner (Chichester, 2005; ElGindy, 2002; Kulwicki, 2003).
• Whether attended by a male or a female health practitioner, demonstration that the practitioner is familiar with and respects women’s health-related cultural and religious beliefs and practices makes a significant difference.
  “Sometimes when the male doctor has a background about our, you know, culture and religion and he respects it that is good. Once I went before the delivery for a check up and it was a male doctor and I found that he can understand it and he suggested that he will let a nurse to check me and she will tell him what she found. He was very helpful” (Reitmonova & Gustafson, 2008, p.105).
• Specifically, ask women if they have any special birth practices or traditions. Document individual requests in the medical records and communicate these requests with relevant staff.
• Permitted and forbidden food and medication considerations. Medications which contain alcohol, or some form of pork or it’s by products are forbidden (eg gelatine-coated pills). Arrange for non-pork alternative medications to be prescribed.

Fasting in pregnancy

• Islamic law gives women clear permission not to fast during Ramadan. However, some women choose to fast. There is no evidence that fasting will adversely affect maternal health. The following information should be given to fasting women:
  • It is best to get a general health check before deciding to fast.
  • If Ramadan coincides with summer, this means hot weather and long days, which puts fasting women at greater risk of dehydration.
  • How the body deals with fasting will also depend on:
    • A woman’s general health before pregnancy.
    • The stage of pregnancy.
    • The length of time of the fast during the day.
• Preparing for fasting, the following advice should be given to fasting women:
  • To plan ahead to make things easier during Ramadan.
  • To talk to their obstetrician or LMC to check their health for any possible complications.
  • Fasting is not considered to be safe if the woman has diabetes and is pregnant (Azizi 2010)

• As soon as a child is born, a Muslim father may wish to recite a prayer call into the baby’s right ear followed by a second prayer call into the left ear. Health care providers should allow this to take place (Queensland Health and Islamic Council of Queensland, 2010).
• Another rite which is performed shortly after birth involves placing a chewed/softened date on the baby’s palate before breastfeeding as recommended in Islam. It is known as ‘Takneek’.
• Muslims are required to bury the placenta (which is considered part of the human body and therefore sacred) after birth.
• Circumcision is performed on all male children. The timing of this varies but it must be done before puberty.
• A fetus after the age of 120 days is regarded as a viable baby. If a miscarriage, an intra-uterine death after 120 days, or a stillbirth occurs, Muslim parents may wish to bury the baby.
• The removal of the new-born’s hair soon after birth is practised by many Muslim families. This is usually done seven days after the birth. This can be performed at a later date (every seven days) if the baby requires a prolonged stay in hospital.
• All other rituals for newborns can be delayed and are usually performed at home. When babies require a prolonged stay in hospital, communicating with the parents about other rites and practices is important.
• Muslim women strongly prefer female attendants to care for them during their labour and birth. While it is not always possible, providing the option of a female obstetrician, physician, midwife or a medical student is highly valued. A male physician is acceptable only if there is no other option.
• Women may be late booking an LMC and may not have attended pregnancy and parenting classes. They may have insufficient information about labour procedures and pain management (Reitmonova & Gustafson, 2008).
• Muslim women may request that they remain in hijab throughout the labour and birth process and this should be respected where practicable. If a male practitioner is required, warn the woman ahead of time, as she may have taken her hijab off with female practitioners in attendance.
• For some women, the presence of their husbands during this phase is important to them. However, not all women are comfortable having their husbands present during child birth.
• If assistance from neonatal staff is needed during the birth process, be aware of ongoing modesty and privacy concerns. Let the family know that additional caregivers will be entering the room quickly. If the baby requires special care and is transferred to the NICU, encourage the father to accompany his baby and to perform adhan as soon as the baby is stabilised.
• A Muslim woman is expected to remain calm and avoid complaints during labour. Health professionals should ask women how they express pain in order to be able to provide optimal care and to decrease the risk of inaccurate assessment.
• Letting women and their families know the location of prayer rooms or a private space for prayer is important.
• Birth is a joyous experience for Muslim families. Ask parents if they have any special requests or rituals that they would like to perform during the birth or after the birth. With a normal birth, the father may request to hold his son or daughter immediately to chant the Muslim call to prayer (adhan) in the baby’s ear. The mother or father may also wish to place a very small piece of date that has been chewed by the parent inside the baby’s mouth at birth (Roberts, 2002, p.226).

• For some women, sharing a birthing unit with other women presents difficulties, including sharing a bathroom, and the need to preserve modesty at all times. However, for other women, sharing a room is a positive experience because they have other women to talk to and share their concerns with.
• Giving women time to redress and to put on her hijab is respectful before entering her room or pulling back curtains.
• Halal food is required. Explicitly ask Muslim women about their specific food preferences.
• One woman recounted a very positive experience with a nurse willing to learn from her cultural traditions. One nurse came and showed me how to give my baby a bath and I told her that I know it in a different way. I use a different way. And she said when I showed her: ‘It’s perfect. Better than me.’ She appreciated it. She said: ‘If you know any information different just teach me and let me know.’ She was very happy and excited (Reitmonova & Gustafson, 2008).

• Muslim teachings recommend breastfeeding for the first two years. However some cultures may not fully support the mother exclusively breastfeeding for the first six months. It is important to ask the mother if she has support from her family to fully breastfeed. Some families cannot tolerate the baby crying and may pressure the mother to introduce a supplement to ensure the baby is well settled.
• If a woman breastfeeds a child (not her own) aged two years or less, the relationship between the woman and that child is considered to be like mother and child. The woman’s biological children are also considered brother or sister to the breastfed child. However, the relationship between the child and its biological mother is not changed.
• Some women, who have chosen to breastfeed, may not do so until the colostrum is fully expressed. LMCs need to emphasise the importance of colostrum as part of breastfeeding.
• Providing privacy is an important factor in supporting Muslim women to breastfeed their babies.
• In the NICU, privacy for women is needed when using a breast–pump and when breastfeeding her baby.

• The need for emotional support and help during the pregnancy and postpartum phases is common among all women but is more acute among migrant women because in many cases family and social support is far away and women may experience extreme loneliness at this time. LMCs may be the only outside people women meet regularly during their pregnancy. Women look forward to these appointments hoping to receive the advice that they would normally get from their mothers or sisters.
• In some cases, living in an extended family situation may increase the risks of postnatal depression (PND) due to conflicting ideas about pregnancy, birth and child rearing and the pressure to follow traditional cultural beliefs.
• Ensuring that women are linked to a Well Child/Tamariki Ora provider and other health care providers who can offer information, help and support reduces social isolation and establishes social support networks in their community.
• Bina (2008), in an Australian study suggests that Arabic women’s expectations of support may be higher than for other groups in accordance with the community support available in home countries during the postpartum phase.

(Waitemata DHB, eCALD® Services, 2015)

• Hand shaking occurs between same sex members only. Physical contact with women should be restricted to necessary physical examinations as propriety is required and highly valued.
• It is customary to greet males first.
• Use a woman and her other family member’s title and last name when addressing them.
• The right hand placed on the heart after hand shaking or greeting is a gesture of sincerity.
• Pointing a finger is considered rude, and either the right hand or both hands are used to pass objects, NOT the left alone.
• Showing respect, especially for elders, is appreciated (eg the health practitioner being on time for an appointment, greeting elders first, and greeting older people in their traditional way).
• It is advisable for health care providers to be modestly dressed to avoid embarrassment.
• Avoiding direct eye contact is considered respectful, especially between men and women, and between people considered to have different status. A person with lower status may lower their eyes, or head to avoid eye contact.
• Saying ‘no’ directly is not courteous in many Muslim Middle Eastern, Asian and African cultures so an affirmative response from a woman and her family may not necessarily mean agreement or acceptance. Alternatively, the client may answer with “I don’t know” rather than saying no. (Women will also appreciate a more indirect way of saying ‘no’ from the health practitioner).
• Beginning with asking general questions about the wellbeing of the woman (and importantly her family), will assist you with establishing rapport and is more likely to engage the woman to volunteer information during history taking.
• The Western custom of asking direct questions is considered impolite and can result in reticence to engage.
• Health practitioners are considered to have a high status and women and their families will not ask questions as it is considered disrespectful. Women and their families will expect that the health practitioner is aware of this and will wait for the health practitioner to invite them to ask questions.
• Showing an interest in the family’s culture and spiritual practices will enhance the relationship between the woman and the health practitioner.

For home visits:

• Give a clear introduction of your role and the purpose of the visit.
• Check whether it is appropriate to remove your shoes before entering the home (notice whether there is a collection of shoes at the front door).
• If food or drink is offered, it is acceptable to decline politely even though the offer may be made a few times.