gms | German Medical Science

Introduction: Ramadan, the Muslim holy month of fasting, is a form of intermittent fasting, characterized by fasting during daylight hours and unrestricted dietary intake during nighttime. Pregnant individuals are exempt from fasting if they have health concerns for themselves or their child. Previous work on Europe and Asia shows that fasting rates during pregnancy vary - from around 50% (Germany, Netherlands, UK) to over 85% (Singapore, Pakistan, Bangladesh). Ramadan during pregnancy has been associated with various adverse health outcomes, including childhood growth and chronic conditions in adulthood [1]. Recent findings from Germany indicate that the impact of fasting on neonatal health may be moderated by maternal diet during the non-fasting hours of Ramadan, with adverse effects on birth weight only identified among women who reduced fatty food intake during Ramadan [2]. This study for the first time examines Ramadan practices among pregnant Muslims in a West African setting, exploring not only fasting prevalence, but also associations between dietary adjustments and neonatal health.

Methods: Between July 2023 and February 2024, we conducted a survey among Muslim mothers in Kaduna, Nigeria. Participants were approached in obstetric wards and immunization clinics (six weeks postpartum) to assess adherence to Ramadan 2023, which overlapped with their pregnancy. Additionally, we collected data on covariates such as socio-economic characteristics and childbirth history. Of 2135 approached women, 92% consented to participate. We excluded 160 observations on women who conceived after the end of Ramadan 2023, 8 with missing birth dates, and 37 with babies born prior to Ramadan. Observations of 1792 mother-child pairs were included in the analysis. Univariate analysis compared fasting and non-fasting women. Interview data were linked to health information from obstetric wards, including birth weight information for 1090 newborns. To investigate associations of fasting and maternal diet during Ramadan with offspring birth weight, multivariate regression analyses were conducted. The Oster method was used to assess potential residual confounding [3].

Results: More than 87% (n=1570) of the interviewees reported fasting during pregnancy. Among the fasting women, a majority (79%) fasted for more than 20 days. Primiparous women and those concerned about potential adverse effects on their baby’s or their own health were less likely to fast (for all comparisons: p < 0.01, X² test). Multivariate regression results indicate that fasting women had babies with lower birth weights (-218g, 95% CI: -312g ; 124g). However, fasting women who increased their food intake gave birth to babies with higher birth weights as compared to fasting women who did not increase their food intake during Ramadan (111g, 95% CI: 43g ; 1279g). Similar positive effects on birth weight were detected when examining increased fatty foods intake (106.26g, 95% CI: 38g ; 175g) separately. Increased water intake during non-fasting hours was also associated with higher birthweights (142g, 95% CI: 69g ; 216g) among fasting women. Results from the Oster method suggest that unobservables would need to be more than 9 times as important as included covariates to nullify the detected associations, indicating that the findings are likely not driven by residual confounding.

Conclusion: Ramadan during pregnancy is of high public health relevance in Kaduna. Our results underline that dietary intake of fasting women during the non-fasting hours of Ramadan might mitigate adverse effects on birth outcomes. This confirms recent findings on Ramadan during pregnancy in Germany. Ramadan traditions vary considerably across and within countries, so that additional evidence on the role of dietary intake in other contexts, as well as specific micro and macronutrients, will be pivotal for designing comprehensive guidelines that can assist pregnant Muslims and their healthcare providers during the pregnancy and family planning phase globally.

The authors declare that they have no competing interests.

The authors declare that a positive ethics committee vote has been obtained.