As a part of the training to become a doula, all of our students go through a module where they learn about different cultural traditions and ceremonies during the perinatal period. Please enjoy this wonderful essay by Halima Sadki on the Islamic traditions of the postpartum period.

Nawal from Egypt

By Halima Sadki

Nawal started her story by saying that in Egypt, pregnancy is almost never a secret within the family. It is known from the first-time mom starts having her morning sickness symptoms. Nausea, vomiting, and fainting are usually the key. One thing Nawal remembers very well is that her cravings were very bad but she said that she was very lucky that she delivered amongst her family and relatives that cooked and provided her with everything she thought of. Her childbirth was very long and unmedicated. As usual, it was attended by the mother in law, her mother, and the Daya (uncertified midwife). The husband is usually very involved in the pregnancy, particularly when the couple lives independently. However, his participation or any other male figure’s participation in the delivery is almost null.

After her delivery, the mother starts a resting period called a “Nifass” (postnatal bleeding). It is about 40 days for most Muslim scholars where the mother is not allowed to have any sex with her husband but she could enjoy everything else. She is exempted from performing the 5 physical prayers and fasting, as long as she continues to bleed. Once the bleeding stops, even if it is less than 40 days, everything returns to normal, particularly her sexual relationship with her husband.

The fetus and the newborn have many rights in Islam. As any Muslim around the world, Nawal said that she followed these religious traditions that are a must:

1. Adhan (the call to prayer) is whispered on the right ear of the newborn as soon as he is birthed. Iqama (2^nd call of prayer) is whispered on the left ear.
2. Tahneek: is the rubbing of the baby’s cheeks with fruit dates (or honey) right after birth. (this is less practiced among the new generation)

3. Breastfeeding or wet nursing for up to 2 years (for those who choose to complete the term)

1. Aqiqah/Sebou’ (party day that happens on the 7^th day): A party for the parents to be thankful for the great blessing of having an offspring. They sacrifice 1-2 sheep to share the happiness with the community and feed the poor.
2. The Purifying (MALE circumcision): Among the hygienic purposes of the circumcision is the protection of the clothes, the penile, and the groin area from getting soiled after using the bathroom. Otherwise, this would nullify the physical prayer.
3. Naming the child:  this became one of the most fundamental rights of the newborn in Islam. That is why, it sometimes takes forever to choose a name. It is carefully picked by the parents and consultations are done with very close relatives. The name has to either have a positive and significant meaning in Arabic language or an Islamic one. The name is announced in the Aqiqah day. Nawal explained that her name in Arabic means generosity, gift, and kind characters.

7. The shaving of the baby’s hair: the hair is shaved, weighed, and the equivalent amount, in gold or silver, is donated to the poor. It is done on the 7^th day as well.

What Nawal likes about these traditions is that they bring the family and community together. Everyone feels that there is this an outpouring sense of sharing, helping, caring, and love.

She added that there are few non-religious rituals that are discouraged in Islam but very important to the Egyptian families. The customs that she doesn’t like or agree with are those concerning the evil eye. She thinks that her ancestors adopted them because high mortality of babies and new moms were common in the old days. So, for some people, those rituals somehow have an effect in protecting them. For example, the Sebou’/party day usually starts with scattering salt on the mother and around the entire house to keep evil eye away.

After bathing the newborn and putting on the new clothes, the infant is carried on a tour and followed by family members chanting and dancing while holding candles. The mother has to step over the baby 7 times without a single touch to the cradle. Meanwhile, the grandparents are making loud noises to intentionally make the baby aware of them. Gentle shaking to the cradle, while ordering the baby to obey the family, is done in a horizontal way and manages to comfort the baby, if startling. This is believed to strengthen the infant.

Taaweez: the practice of tying a black piece of string to a prayer contained in a small pouch is also very widespread among Muslim cultures although the religious scholars of Islam continue to criticize it on a regular basis. This string is usually tied to the baby’s wrist or around the neck. The common belief is that this will protect babies from ill health and evil eye.

Quran: Some believe that carrying the glorious book or putting it in the baby’s crib has a protective value as well.

Nawal wishes that the female genital mutilation is completely banned. It is a very common and practical custom in Egypt among both the Coptic Christians and the Muslims. Some believe that it dates back to the pharaonic area where it was used as a cosmetic measure. Others still believe that it is necessary to control female sexuality. Even though some Muslim scholars believe that it should be completely banned, there are others that support Al Khifad which is a much simpler procedure and is not regarded as FGM, so, they should never be used interchangeably. She clarified that Islam protects the woman’s right of sexual enjoyment. If Al Khifad enhances the wife’s sexuality and promotes her wellbeing, then it is permissible. However, if it would violate this right or harm her in any way, then it should be forbidden. She added that the procedure must be done only by a specialist in the field and the female has to complain of chronic infections, inflammation, or decreased sexual desire which are very rare.

Leila from Morocco

By Halima Sadki

Leila had a unique childbirth experience because she had one child in the urban side of Morocco and the other one on its rural side. She said that in the urban areas, moms are no longer giving births at home like before. The natural and unmedicated birth is replaced with a more complicated one in the clinics where moms could opt for a c/s just to avoid the pains of labor and delivery and the newborn is kept in a separate room so that mom could rest. The baby is formula fed all night long because there are no wet nurses in the clinics or hospitals. The mother is cared for in the clinic for few days and when she goes home, few people from the immediate circle would visit. Once mom is ready to finally start breastfeeding, either latch is difficult, mom is engorged, or supply is low, or she has no support. It is a very sad reality, she concluded.

The second time around, Leila decided to have her baby among her family in the North. There, hospital births are still rare and birthing in the clinics is expensive. As any pregnant mom, Leila appreciated the extra attention, the love, and the whole thing about pregnancy and birth in the traditional fashion. Of course, the importance lessens with the subsequent experiences but the atmosphere is still good and positive, she explained.

Although a pregnancy remains a secret until symptoms show, the mother is always assisted with most of the chores by female family members and neighbors. Once the cravings start, a special dish “Rfissa” is made to celebrate and announce the pregnancy to the community. It is a common cultural belief that if a mom craves a certain food and she is not able to have it, she might itch her skin, which would develop into a purplish birth mark after birth! So, the generosity of the community helps that mom remains well fed at all times. In the last week of her pregnancy, the pregnant woman’s mom joins her for moral support. She would take care of her and her newborn until the Aqiqah party.

In the religious tradition of the Nifass (post-natal bleeding) all kind of intimacy with the husband is encouraged, except penetration. This resting period allows a mom to eat well, breastfeed, and enjoy taking care of her infant. The end of this 40-day period is marked with one small party and is still exaggerated, in some places, with another month of rest at her mother’s house this time. This would allow a total of 2 months of rest as practiced by the ancestors.

Leila shares all Nawal’s religious traditions, since she is a Muslim too including the Adhan, tahneek, breastfeeding or wet nursing, shaving of the head, naming the baby, Aqiqah, and male circumcision. She explained that in the rural areas, they still feed baby honey and ghee if the wet-nurse is not yet available and mom has no colostrum. I asked her about female circumcision either among the Muslim or Christian minority females and she said that it is completely unheard of in the entire territory of Morocco (in spite of the fact that some scholars believe that it should be done if medically indicated following the Islamic guidelines). However, male circumcision is a must for every single male. One positive change is that people used to procrastinate on doing it if the birth was in the winter. They would postpone it until after weaning, then until after toddlerhood. It was even harder if done when the baby got older. Nowadays, people are getting it done much sooner again.

Because children are so precious and due to high mortality in the old times, few non-religious customs prevailed in Morocco too, just like Egypt. It was considered bad luck to buy items for the baby before birth or the gender was known. Also, it was a practical custom to put only old clothes on the newborn on the first day. Things are changing and neutral or new colors might be used now. Likewise, fear of evil eye is still common, mostly in low socioeconomic areas. For instance, some families will still keep baby hidden until the 7^th day. The same goes for the chosen name.

While the majority of Muslims use incenses because they purify the houses from bad odors and have benefits to the health and soul, some people like to believe that igniting them prevents the demons from entering the house, blesses it, and protects mom and baby from envy and potential injuries.

One practical and fun custom that Leila bragged about was the henna, which is done before the party. Her Kabla (traditional midwife) and her maids took her to the public bath. They massaged her body with oils and herbs and gave her a facial. The oldest lady massaged her tummy and the uterus. After that, they clothed her like a new bride. Everything was white and new. Beautiful Henna designs were tattooed all over her arms, hands, and feet and golden jeweler was put on. The baby was well dressed too. The Aqiqah feast is usually celebrated with music and ends with guests giving mom and baby gifts, money, and gold.

Unfortunately, the religious tradition of wet nursing is disappearing in the urban areas. Some new moms are satisfied with formula either because they have to go back soon to work or they live far away from work. Hospital grade pumps are rarely available. Breastfeeding in public, however, remains popular.

At the time of Leila’s mom, there was no specific prenatal care for pregnant women. Visits to the doctors were not needed if a pregnant mom was not suffering. Natural remedies and herbs were preferred over drugs. Old generations conceived very young, were pretty healthy, and averaged 8 kids per family. One advantage of today is the benefit of immunizations.

Last night, New York Governor Andrew M. Cuomo announced a series of initiatives with the goal of reducing maternal mortality rates in New York State. In his words, “Maternal mortality should not be a fear anyone in New York should have to face in the 21st century.” Indeed, this sentiment could be echoed by any of the other 49 states. Compared to other wealthy nations, the US’s maternal mortality rates are soaring.

The pilot program is set to be finalized and put into action within 45 days. Specifically, it would aim to improve mortality rates for black mothers. In New York State, black women are four times more likely to die in childbirth than white women. In New York City, this statistic skyrockets to 12 times more likely. This goal will be accomplished by expanding Medicaid coverage for doulas.

Why doulas? The reason is two-fold.

First of all, studies show that having a birth partner provide one-on-one support to mothers throughout labor and delivery leads to better outcomes for mom and baby. This is precisely what trained doulas are taught to do.

Secondly, despite the advantages, doulas support is only utilized. For some, the cost can be prohibitive. Studies also show there is little diversity among doulas. Therefore, although black and low-income mothers may want the support, their access may be inadequate.

The hope is that expanding Medicaid coverage for doula services would bridge the gap of racial disparity.

If successful, New York will be joining Minnesota and Oregon as the only other states that offer this kind of coverage. However, the initiative is not without concern. Medicaid reimbursement rates for doula support in Minnesota have been low. There’s also concern that the expansion could potentially alter the doula profession.

Molly Deutschbien, a committee member of Rochester Area Birth Network, is in support but still has concerns: “When the doulas get paid by someone other than the mother, it gets to the question of, who does the doula work for?”

Conversely, Elan McAllister, a former doula, and co-founder of the New York Coalition for Doula Access believes this is a positive step, saying “We see it as this critical piece of improving outcomes most especially for at-risk mothers. There’s something about having a support person who can bring humanity into a situation and who cares that you survive childbirth and get through it.” (https://www.nytimes.com/2018/04/22/nyregion/childbirth-death-doula-medicaid.html)

Aliza Bancoff, the founder of International Doula Institute, is pleased with this step toward more doula-attended births in New York.

In her words, “we know that having a doula present reduces many common difficulties during childbirth, including lowering cesarean rates, decreasing the need for pain medication, and decreasing mortality rates, among others. So to have doulas covered under Medicare is a great step forward.”

Governor Cuomo will also create a Task Force on Maternal Morality and Disparate Racial Outcomes to partner with the Maternal Mortality Review Board. The plan will be to review each maternal death in New York. Additionally, the state will expand prenatal education programs and review hospital best practices regarding hemorrhaging.

Overall, Cuomo says, “We are taking aggressive action to break down barriers that prevent women from getting the prenatal care and information they need.” (https://www.nytimes.com/2018/04/22/nyregion/childbirth-death-doula-medicaid.html, New York to Expand Use of Doulas to Reduce Childbirth, accessed April 23, 2018)