Archive for April, 2011

Postpartum Care Considerations in Muslim Communities: Part II of the Interview with Hajara Kutty.

April 29th, 2011 by avatar

Walker: Tell us about postpartum care in Muslim families. In your experience, how is a woman supported by her family when she comes home?  Are postpartum doulas ever employed?

Hajara: From a purely religious standpoint, postpartum women are exempt from performing the five daily prayers and are not to engage in conjugal relations for forty to sixty days after birth – that in itself is a huge relief! There are however, no specific Islamic guidelines on how a woman should be cared for postpartum by the family.

And so again, where there is no religious guideline on a given matter, people are free to and often will follow the protocol of the culture they most identify with. And so this is why you’ll find Muslim women of East Indian origin moving in with their moms’ for the first couple of weeks up until a month.

In terms of if postpartum doulas are ever used, though I don’t personally know of any Muslim couples that have opted for a postpartum doula, there is nothing really preventing Muslim couples from employing one.

Walker: Can you tell us what, if any, differences there are regarding choice or preference to breastfeed?

Hajara:  There are actually a few Islamic guidelines on the issue of breastfeeding. Firstly, breast milk in Islam is considered the newborn’s birth right, something he/she is entitled to. And secondly, moms are allowed to nurse their baby up until the age of 2, at which point they should wean their baby.

All that being said, it needs to be noted that if a mom is not able to breastfeed for reasons like insufficient milk production, physical issues, mental health concerns or because she has to return to work, she is Islamically exempt from breastfeeding duty. In such cases, a woman can opt to provide: a milk-nurse for her baby (think of Salma Hayek’s trip to Sierra Leone in 2009), a healthy alternative like formula* or opt for a combo of some sort like pumping and supplementing (if the issue is due to return to work).

Walker: Regarding emotional health in the postpartum period, what is your experience of supporting Muslim women who have a perinatal mood disorder?

Hajara: My experience supporting Muslim women with a perinatal mood disorder has been somewhat (no pun intended) depressing.

To better explain what I mean, it’s important to understand how Islam views mental illness in general. If you actually look at Islamic history, you’ll see that many of Islam’s greatest scholars and physicians were among the first to view mental illness as actual medical conditions. And this was at a time when most of the world opted to view mental illness as evidence of demonic possession.

In fact, two Muslim giants made some of the greatest contributions to the field of psychiatry at the time: with Avicenna (considered the father of modern medicine) including mental illnesses in his Canon of Medicine and Rhazes being the first to open a psychiatric ward.

Muslims were also among the first to treat those with mental illness compassionately as dictated by the Qur’an, use baths, drug treatments and even use music therapy to help treat mental illness!

Now the depressing part: practically no one, no Muslim I’ve ever met, including Muslim women with perinatal mood disorders and their families that I have had to support, knows what Islam’s view on this topic is.

Not only do they not know how supportive their faith is about this topic, a good majority of Muslims tend to believe quite the opposite: that the Islamic perspective on mental illness is that it is due to a lack of faith, punishment, or my all-time favorite, demon possession!

Because of this, in my experience, a lot of Muslim women don’t want to admit to any of the symptoms of a perinatal mood or anxiety disorder, thinking it means they are not committed enough to God, etc.

I have also come across families that have simply watched their loved one spiral into postpartum psychosis and done nothing believing their loved one is possessed!

And so, my experience in supporting Muslim women with perinatal mood disorders has been fraught with an additional layer of stigma and ignorance that has to be chipped away at.

Though it is truly unfortunate, I can’t blame people for not knowing about the Islamic viewpoint on mental illness. Having done my studies in Psychology, never once was I even exposed to what anyone outside of Europe believed about mental illness. And this was at a University known for being left-leaning!

Closing thoughts…
Increasing our knowledge of the cultural context of maternity care is essential to addressing the full spectrum of reproductive health on the global scale.  My gratitude to Hajara for her participation, knowledge, and steadfast commitment to the perinatal mental health advocacy movement.

Hajara Kutty is an educator and postpartum mental health advocate. She is also the Greater Toronto Area Coordinator for Postpartum Support International. Her articles on the topic of postpartum mental illness have appeared in media outlets across Canada. She lives in Toronto with her husband, daughter and cat.

Posted by:  Walker Karraa, MA, MFA, CD(DONA)

Childbirth Education, Patient Advocacy , , , , ,

Gifts from God: Childbirth and Postpartum Care in Islam

April 29th, 2011 by avatar

Join me in this amazing opportunity to learn about culturally competent maternity and postpartum care for Muslim women.  Educator and postpartum mental health advocate Hajara Kutty shares invaluable religious and cultural context for birth and postpartum care in Islamic families.   Part I of my interview discusses childbirth practices and ways to integrate cultural competence in childbirth education.  Part II will cover postpartum care, including breastfeeding, and emotional support.


Walker: Can you describe some of the general cultural and religious guidelines surrounding labour and the birth of a baby in the Muslim culture?


Hajara:  In the context of Islam, the birth of child (girl or boy) is a very joyous event; all children are seen as gifts from God.

In the Qur’an (Muslim Holy Book), childbirth and labour are recognized as extremely painful and taxing experiences. In the Qur’anic rendering of the story of the Mary mother of Jesus (a respected Prophet of God according to Islam), it quotes Mary as saying while in the throes of labour, “Ah! Would that I had died before this! Would that I had been a thing forgotten!”

The physical and emotional pain a mother endures during pregnancy, labour, delivery and postpartum is but one reason why Islam accords such an elevated status to mothers.  In this regard, the Qur’an reminds people to, “Respect the womb that bore you.” Additionally, some of the traditions and sayings of the Prophet in this regard include: that one owes to their mothers three times more love and obedience than that owed to one’s father, and that “Paradise lies at the feet (serving the needs) of one’s mother.”

There are really no guidelines around labour, but as per the example set in the story of Mary, it is seen as a time to turn to God for comfort and assistance.

When it comes to the actual birth, there are a few important practices that need to be kept in mind. Upon the child actually entering the world, one of the first requirements is for the father to recite the adhaan (call to prayer) in the ear of the newborn. This is so that among the first sounds the baby hears are words declaring the Oneness of God. Another practice that is highly recommended (but not required) is to mash a dried date between one’s fingers and let the baby have a taste or lick. This particular tradition hearkens back to the Prophet Muhammad who did this for his grandsons and other newborns brought to him after their birth. It is in acknowledgment of the newborn’s need for nourishment and the fact that dates have the highest natural sugar content. Lastly, if the baby is a boy, arrangements need to be made for him to be circumcised.

Walker: In discussing childbirth education, what are the sources of childbirth education for Muslim women in your area of Toronto?


Hajara: The sources of childbirth education among Muslim women are the same as those for other women: prenatal classes, doctors & of course, friends.  Typically, hospitals where women deliver often offer prenatal classes, but there are also a host of private childbirth educators as well.


Walker: Is it appropriate for a woman’s husband to attend class with her?


Hajara: From an Islamic point of view there is nothing wrong with husbands attending childbirth education classes with their wives.


Walker: If a childbirth educator has a Muslim couple in class, what are specific things she needs to be mindful of?

Hajara:  I can see two issues that childbirth educators may need to be mindful about if they have Muslim couples:
1.      Muslim couples may not wish to watch videos or see pictures of actual births. This is because certain parts of the body (private parts) are considered an individual’s private space and are not to be seen by others, be they of the same or opposite gender, the only exception to this being between spouses or for medical reasons.
2.      Muslim couples may not wish to practice some of the breathing exercises, which may require the mom-to-be to assume actual birthing positions, in front of others.


Walker: Along those same lines, what accommodations should a childbirth educator make regarding information given: videos, handouts, exercises, etc.?


Hajara: Culturally competent ways of giving information may include letting couples know they don’t have to watch the birthing videos if they are not comfortable with viewing it, so in other words, not making it a mandatory component of childbirth education classes.

With regard to the breathing exercises, childbirth educators can let couples know up front that private sessions are available (if they are) and/or let couples know that they are free to do the parts of the breathing exercise they feel comfortable doing and leave out the components they are not comfortable practicing in front of others. If this means a couple ends up practicing the deep breathing without being on their back, so be it!

Walker:  Can you speak to the meaning of dress in Islam for women and how that would translate in child birth and after, and during breast feeding?


Hajara: Generally speaking, Islam has dress guidelines for both men and women, and they are in place for the purposes of maintaining one’s modesty. For women, this includes covering everything except the face and hands in the presence of males that are not part of one’s immediate family. That being said, this dress requirement is entirely waived when medically necessary, for example during childbirth, physicals, surgery, etc.

It’s also important to note that the dress requirement for women in front of other women is significantly more lax and is why breastfeeding in front of other women is not an issue.


Walker: Would you think that a birth plan is an appropriate tool for a Muslim woman to use to state her needs and requirements?

Hajara: It’s my understanding that birth plans are used to communicate one’s needs, wishes and expectations for the labor and birth. If this is the case, birth plans may be the ideal tool to help communicate one’s wishes, including one’s faith based birth needs and requirements.

Walker: Are doulas commonly used?


Hajara: From an Islamic point of view, there is nothing that mandates or restricts the use of labour support, so that would be a decision left entirely up to the individual/couple. Though in my experience, a lot of Muslim women I know have traditionally tended to rely on labour support in the form of their own mom, sister or friend.


Walker: What are the general preferences between birthing in a hospital vs. home births?


Hajara: Again this is something that Islam doesn’t really provide a guideline about, so I would say that the preferences among Muslim women would be the same as what one would see among women in general.


Walker:  You were kind enough to review the Lamaze Six Practices for a healthy birth for this interview, what did you find?

Hajara:  In terms of Lamaze’s 6 practices of healthy birth, none of them appear to be in conflict with the Islamic approach to giving birth!

[Stay tuned for Part II of Walker Karraa’s interview with Hajara Kutty…]


Hajara Kutty is an educator and postpartum mental health advocate. She is also the Greater Toronto Area Coordinator for Postpartum Support International (PSI) www.postpartum.net.com. Her articles on the topic of postpartum mental illness have appeared in media outlets across Canada. She lives in Toronto (Canada) with her husband, daughter and cat.

Posted by:  Walker Karraa, MFA, MA, CD(DONA)

Childbirth Education, Patient Advocacy, Uncategorized , ,

Legal Corner Q&A: Informed Consent (Part 2) (or, “They Can’t Really Kick You Out of the Hospital for Not Following Hospital Policy…Can They?”)

April 28th, 2011 by avatar

[Editor’s note:  This second segment of Ms. Magan’s Legal Corner Q&A, focusing on informed consent, makes a great resource for childbirth professionals to share with their clients in the event that questions surrounding hospital policies/procedures comes up]

A Review

In my first post, I talked about that legal and ethical doctrine,
informed consent, which is founded upon the notion of personal autonomy – a person’s right to decide what treatment to agree to, or refuse – and the health care provider’s obligation to disclose all material facts pertaining to a particular treatment or procedure.

I provided three scenarios in which a pregnant woman could find herself if she ends up laboring in a hospital.  It was determined that, the last of our three examples (your provider comes into your room and forcefully lobbies the use of Pitocin to induce or augment labor) allowed the most straightforward answer (see previous post).

Now, we will address the other two scenarios:

1.        As you walk the halls to bring on labor, a nurse firmly escorts you back to bed, explaining that hospital policy requires you to stay in bed;

2.        When you ask for a glass of water, you are instead poked with an IV because  that’s hospital policy; and the overarching question that affects the analysis of each of the examples — “They can’t really kick you out of the hospital for not following hospital policy…can they?”

Short Answer

Yes, but …

They cannot kick you out if you are in active labor (when the cervix is about 3 – 4 cm), or any other condition that may be considered an “emergency” without violating state and federal law. (e.g., Emergency Medical Treatment & Active Labor Act (EMTALA). Similarly, a physician may not abandon you, meaning he or she cannot “fire” you as a patient without reasonable notice when you still require medical attention. But you want a healthy, happy, delivery, not a potential lawsuit. So what can you do?

What is Hospital Policy and Procedure – Can I See It?

Hospital polices are designed to save money, streamline care and avoid – at least on paper – liability. So, for instance, a fetal monitor may be strapped onto you soon after admission to the hospital, to assess whether the fetus is in distress;  and you may not be allowed to walk the halls after receiving pain medication, including, often, epidurals — the hospital’s policy to avoid falls (rather than hire more staff to ensure safety). Knowing these real reasons for the policies, though, provides you some strength.

I can tell you that, as an attorney, it is often a war to obtain a hospital’s policies and procedures, even in the midst of a lawsuit. But, as the patient, you are armed with that right by virtue of another hospital policy – the Patient’s Rights and Responsibilities.

Obviously, hospital policies and procedures may vary from institution to institution, and even within the hospital, where, for instance, the Labor and Delivery Department may have additional policies that conflict with other general hospital policies. But the hospital’s Patient’s Rights and Responsibilities policies will generally be the same among institutions, because they are written to comply not just with state, but with federal laws. (e.g., the Patient Self Determination Act of 1990, 42 U.S.C. 1395cc(f) (2010), which applies to all Medicare/ Medicaid participating hospitals and facilities). You will usually have to initial something on the hospital’s admission papers/consent for treatment form that you understand your rights as described in the Patient’s Rights and Responsibilities brochure, which they oftentimes never provide, but which you can usually find online, or with Admissions at the hospital.

So, when it looks like your preferences for a natural birth are being unfairly dashed, here are some of the rights you will find in, or that flow directly from, your hospital’s Patient’s Rights and Responsibilities (or Patient Bill of Rights) policies that you can use to negotiate treatment that better suits your desires:

Example: You would prefer to walk in order to help labor along; but the staff is insisting that “Hospital Policy” requires that you lay down in bed. Your response might be, “May I please see the rules, because I also understand that perhaps we can negotiate on this point if I accept responsibility for doing so?”

Your support:


•        Know any hospital rules or policies that apply to your conduct while a patient.


•       Accept full responsibility when refusing treatment or not following the physician’s instruction.

Example: “I would prefer a glass of water, not an IV; can’t we agree that I will receive an IV only in the event that I need one?”

Your support:


•        Have your psychosocial, spiritual and personal values, preferences and beliefs respected;

•        Participate in the development and implementation of your plan of care; and

•        Request or refuse treatment, to the extent permitted by law. However you do not have the right to demand inappropriate or medically unnecessary treatment or services. You have the right to leave the hospital even against medical advice to the extent permitted by law, and you have the right to be informed of the medical consequences of any of these actions.

Example: They are treating you like “the difficult patient.” They want nothing more to do with you. You overhear a nurse say, “If she wanted natural childbirth, she should have stayed home.” You think, “Uh-oh…” and say, “I am sorry you believe I am being difficult; I know it is my responsibility to report any concern I might have, and I simply have a concern that this is not best for me or my baby; I would like to talk to someone about this…”


Your support:


•        Report any unexpected changes in your condition or any difficulties or concerns you have as soon as possible;

•        Make any concerns, complaints, or grievances known to your care provider  in order that they may be resolved in a timely manner by either the immediate healthcare provider or by hospital administration;

•        (You also have the right to participate in ethical questions that arise in the course of your care, including issues of conflict resolution…)


In Sum

Your relationship with any health care provider is based on trust. It is extremely important that you know your rights and establish relationships with those health care providers who will support your wishes. Your birth plan is not a contract, and neither your maternity care provider, nor the hospital, has to comply with it. But take it, and your questions to both your doctor and hospital in advance. Learn what their standard procedures are. Discuss your desires and objections in the context of the hospital’s Patient’s Rights and Responsibilities policy.  If your birth plan and concerns are vetted beforehand, it is more likely that you will be able to reach amicable solutions to any problems ahead of time, rather than in the throes of labor.

Posted by:  Casey Magan
Waddell & Magan, PC


Disclaimer – Although we go to great lengths to make sure that the information we present here is accurate, please know that legal information is not the same as legal advice and does not apply the law to an individual’s specific circumstances. Please consult a lawyer if you want professional assurance that our information, and your interpretation of it, is appropriate to your particular situation.


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Lamaze Breathing: What Every Pregnant Woman Needs to Know

April 27th, 2011 by avatar

The Spring (20.2) issue of the Journal of Perinatal Education is already upon us, and this month’s Continuing Education Module is by our own Judith Lothian, PhD, RN, LCCE, FACCE.

In her article, Lamaze Breathing:  What Every Pregnant Woman Needs to Know, Dr. Lothian reviews the history of the Lamaze organization and its initial focus on breathing-as-pain-reduction.  Describing the birth of the Lamaze method, when Marjorie Karmel brought her experience birthing with Dr. Fernand Lamaze in Paris, France, to the United States and subsequently paired with Elizabeth Bing to form ASPO (now Lamaze), Lothian states:

“…conscious relaxation and controlled breathing [were used] to manage the pain of contractions, avoiding the need for drugs.”

Lothian goes on to suggest that Lamaze’s focus on breathing as a pain reduction strategy, in all its simplicity, tended to “work” well at the time because, “in those years, labors routinely started, continued, and ended naturally.  Intravenous fluids, continuous fetal monitoring, and epidurals were not part of typical labor.  The cesarean rate was 6%.”

And yet, as we all know, the labor and birth environment here in the US has become more complicated since the early 1960s when the Lamaze approach to labor and birth first took hold.

In my childbirth education classes, when discussing breathing and relaxation techniques, I often find myself asking for a show of hands: “How many of you in this class have ever participated in an athletic activity before?”  Most, if not all hands, typically rise. The line of questioning further unfolds like this:

“What happens when you find yourself going from walking…to jogging…to running…to sprinting?  What does your heart begin to do?  What about your breathing pattern?”  The answers, of course, are that heart rate and breathing increase to match the body’s level of effort.

Then my questioning continues.

“What kind of breathing pattern occurs when you hurt yourself, such as stubbing your toe, spraining an ankle, hitting your thumb with a hammer?”  The answer, of course, is no surprise again:  your breathing automatically changes:  perhaps you suck in a quick breath, hold your breath, or take a series of long, deep breaths while adjusting to the pain of the injury.  Alterations in breathing happen naturally.

Members of the hiking/mountain climbing arena may be familiar with the guidance about breathing touted by the famed mountaineer, writer, and founder of National Outdoor Leadership School, Paul Petzoldt, in his book, The New Wilderness Handbook (Petzold, Ringholz, 1984).  Petzoldt  described using rhythmic breathing to control the hiker’s pace and thereby prevent the need for auxiliary oxygen (even at high altitude) as well as avoid potential complications of altitude sickness such as hallucinations, headaches and faulty decision making.

Conscious breathing, as it turns out, really isn’t just a “Lamaze thing,” after all.

Birth, of course, is neither an injury nor a trek up K2 (though, it might feel like the latter at times).  It is a normal event in the continuum of a woman’s lifespan.  However if we, as childbirth educators, help our students tap into the natural ways their bodies already can and do utilize altered breathing—be it during exercise, athletics or injury—then we can more easily convince expectant parents that they already know how to use breathing as a pain-coping technique.

Lothian’s article goes on to described how, since the ‘60s, Lamaze has moved away from “prescribing” particular breathing methods and, instead, encourages women to tap into comfortable and yet purposeful breathing patterns that feel right to the individual. Moving from strict guidelines which suggest the “one right way” to breathe during labor and birth, a more organic, nimble and responsive approach to breathing-as-pain-reduction (and distraction) is urged.

And yet, there are practices out there, which many women find helpfully applicable to labor and birth, which do combine specific breath work with specific intention.

A friend of mine, Gloria Overcash, teaches both Kundalini and Khalsa Way prenatal yoga classes. During a recent class for members of our local birth network, Gloria introduced us to some of the breathing methods she teaches her students, along with the purpose behind the methods.  Here are some of her insights:

“The science of breathing, known in yoga as Pranayama, is incredibly useful for pregnant women in a variety of circumstances.  A simple, long deep breath can bring one back to the center in the most chaotic of times.”

Here, I think of the usefulness of a calming, purposeful breath to help a laboring woman relax during a vaginal examination, during the insertion of an IV catheter, if needed, or following the conclusion of a contraction.

“There are a number of breathing exercises I teach in my prenatal classes to support mental and emotional balance,” says Overcash, who recommends practicing breathing techniques in a cross-legged, seated position, or in a chair with a straight spine.  “The chin is tucked slightly.  The eyelids are closed and the eyeballs are rolled up, focusing on the “third eye,” also known as the brow point, between the eyebrows.  This ‘drishti,’ or eye focus, stimulates the pituitary gland, the ‘master gland,’ regulating the secretion of the thyroid, adrenal and reproductive glands while also increasing a mother’s intuition.”

When addressing use of the breath for relaxation during the active phase of labor, Gloria suggests, “Women in the active phase of birthing are encouraged to breathe naturally and consciously, creating a rhythmic focus which helps facilitate relaxation and a meditative state while also providing needed energy.”

Lothian does a fantastic job outlining the progress Lamaze has made over the past fifty years teaching women about the labor process and methods of relaxation and pain-coping.  Summarizing the journey of her article, and of Lamaze International, in general, Lothian states:


“Although many women continue to think of Lamaze as ‘breathing,’ it is no longer the hallmark of Lamaze.  The six Lamaze Healthy Birth Practices (2009) are the foundation of Lamaze preparation for birth and reflect the evolution of the Lamaze approach to childbirth, one that incorporates a more complete understanding of the physiology of labor and birth and the danger of interfering in the natural physiologic process of birth without clear medical indication.”

As always, Lamaze members can access the entire JPE on-line for free, and Springer Publishing also makes the Table of Contents as well as a couple select articles (including the one featured here) free to the general public.  To complete the continuing education modules based on JPE articles, go here.

Journal of Perinatal Education, Lamaze Method, Lamaze Official Guide Book , , , , , , , ,

Calling All Science & Sensibility Readers: Amnesty International’s “Beads of Strength” Bracelet Giveaway Contest!

April 26th, 2011 by avatar

The Lamaze International organization has worked, for fifty years, to promote natural, healthy and safe approaches to pregnancy, childbirth and early parenting practices.  And it is so good to know, we are not alone.  With Mother’s Day quickly approaching, Science & Sensibility will spend all next week featuring organizations whose primary purpose is to make life better for mothers.  But, we didn’t want to leave you, our dear readers, out of the festivities!  And so, over the next 12 days, you have the opportunity to submit your story on how you especially honor mothers in your maternity care-related practice.

This is a call out to all national and international midwives, physicians, doulas, childbirth educators, therapists…anyone who works with women of childbearing age.

Submit your story to me at kmh [at] pregnancytoparenthood [dot] org, by next Friday night, May 6, at midnight EST (4:00 a.m. Saturday May 7, GMT) and a randomly-selected winner will receive this gorgeous Multicolor Beads of Strength Bracelet from Amnesty International:
















On Mother’s Day, I will announce the winner, as well as post all stories received,  for everyone to enjoy.
Happy writing!

Posted by:  Kimmelin Hull, PA, LCCE

Amnesty International, Awards, Blog Carnivals, Lamaze News, Patient Advocacy, Uncategorized , , , , , , ,

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