Islam is the fastest growing religion globally. There are currently 1.8 billion Muslims worldwide and this is projected to increase by 70%, so that, by 2060, Muslims will account for 3 billion of the global population (Pew Research Center, 2017). Here in the UK, the number of people who identify as Muslim has increased from 3.0% to 4.8%, or a population of 2.7 million people, making Islam the second largest religion in the UK (Office of National Statistics (ONS), 2011).
Perinatal mental health manifests as depression, anxiety disorders and postpartum psychosis. These disorders can occur throughout the childbirth continuum; both during pregnancy and up to the first year postpartum. Approximately 20% of women experience perinatal mental illness in the UK, making perinatal mental health a common issue (O'Hara and Wisner, 2014).
The number of perinatal mental health services sadly does not meet the prevalence of the illness, with less than half of mental health Trusts providing a specialised perinatal mental health team staffed by a lead consultant perinatal psychiatrist (Joint Commissioning Panel for Mental Health, 2012). While some Trusts will have access to this service, others will have to rely upon adult mental health services alone in order to adapt their approach to a maternity situation.
The Muslim community comprises of many different ethnicities. Those of Asian origin make up 68% of the UK Muslim population, with Pakistanis making up 38% of this group (ONS, 2011). Although there are few statistics on the number of Muslim women who experience perinatal mental health issues, Husain et al (2012) found that depression was higher among Pakistani women in the UK (31.0%) compared with white European women (12.9%).
The Qur'an, the Muslim holy book, and the Hadith, or sayings of the Prophet Muhammad, offer Muslims guidance in all aspects of their lives. According to Islam, health is maintained through a balance between the mind (Aql), body (Jism), self (Nafs) and spirit (Ruh) (Ally and Laher, 2008). Mental health is therefore recognised within the religion through ‘the mind (Aql)’.
This article aims to discuss common factors that may predispose women to perinatal mental health, from an Islamic perspective. This in turn may aid a better understanding among health professionals who care for and aim to engage with Muslim women.
Causes of perinatal mental health issues
Although there is no definitive explanation for why women develop a perinatal mental illness, there are some risk factors that can predispose women to the condition. These include previous experience of mental health problems; a lack of support; a troubled childhood (if a women experiences neglect, for example); experiencing a traumatic event, abuse or assault; a lack of self-esteem; or a stressful living environment (Mind, 2016).
Having an awareness of these risk factors enables health professionals to establish a reason for the illness and decide on an individualised care and treatment plan. An understanding of the woman's spiritual beliefs and needs could further enhance her care.
The importance of motherhood in Islam
The Qur'an recognises the difficulties of childbirth, and states an obligation of respect to mothers in the following passage:
‘His mother beareth him with reluctance, and bringeth him forth in reluctance … My Lord: Arouse me that I may give thanks for the favour wherewith Thou has favoured me and my parents, that I may do right acceptable unto thee.’
‘It should be stressed that this is a cultural problem and not prescribed by religion, and understanding the difference is an important point for health professionals’
Equally, new mothers have a religious duty explained in several Hadith (Sahih al-Bukhari, 6719):
‘The Prophet (Peace Be Upon Him) said: Each of you is a guardian and is responsible for his ward. The ruler is a guardian and the man is a guardian of the members of the household; and the woman is a guardian and is responsible for her husband's house and his offspring.’
The Hadith clearly states the roles and responsibilities of the new parents. According to this religious text, it is the duty of Muslim women to be the fundamental ‘guardian’ of the children. Although many women may feel an overwhelming sense of responsibility to their newborn, it may be that religious importance could be an additional pressure when a woman first enters into motherhood, which could contribute to the women suffering from a low self-esteem and thus a risk of developing a perinatal mental illness. If health professionals are aware of the religious responsibilities prescribed to Muslim women, they can perhaps support her in her transition to motherhood.
Breastfeeding in Islam
Breastfeeding is referred to in the Qur'an, where it states ‘The mothers shall give suck to their offspring for two whole years’ (Surah, 2:233). Muslim women will also be rewarded for breastfeeding, as explained in the following Hadith: ‘For each mouthful of milk that a baby sucks, the mother is given the reward of one good deed’. While Muslim women will be aware of the Islamic teachings of breastfeeding, their midwife will also recommend a period of exclusive breastfeeding for 6 months, followed by complementary foods and continued breastfeeding up to 2 years of age (World Health Organization, 2002).
Kendell-Tackett et al (2011) found that breastfeeding mothers were less likely to report a depressed mood compared to women using a combination of breast and formula, or formula only. This is further explored by Donaldson-Myles (2011), who concluded that breastfeeding mothers were less likely to view themselves as victims of depression. However, it is also well documented that difficulties in breastfeeding can have a negative impact on a mother's mental health (Royal College of Obstetricians and Gynaecologists (RCOG), 2017). Therefore, although women should be made aware of the benefits of breastfeeding, they should also feel supported in whichever decision they make in regard to feeding (RCOG, 2017). Health professionals should be aware that the inability to breastfeed might also make the woman feel she is not fulfilling her religious duties, as well as not providing the best nutrition as recommended by guidelines. These tensions could culminate in low self-esteem and perinatal mental health problems.
Preference of gender and Islam
The Qur'an clearly condemns both discrimination towards women and the preference towards having a son, with passages such as the following reflecting the cultural traditions of the time, when baby girls were traditionally buried alive:
‘When news is brought to one of them, of the birth of a female, his face darkens and he is filled with inward grief!
With shame does he hide himself from his people because of the bad news he has had! Shall he retain her on contempt, or bury her in the dust? Ah! What an evil they decide on?'
Despite the Qur'an criticising and expressing this as an evil, it has been shown that mental illness may exist from inequalities between men and woman. Interviews with 5000 woman in Tunisia found that one in three women agreed that a mother without sons was at risk of being socially outcast (Douki et al, 2007). The idea that a lack of social support could lead to dispute among the family circle is further supported by Winkvist and Akhtar (2000). Their study discovered Pakistani women from a low socioeconomic background were victims of verbal and physical abuse from their partners after giving birth to a daughter.
Health professionals should be aware that, in some cultures, there is still a stigma associated with giving birth to a girl rather than a boy, which can, in turn, negatively impact on the mother's mental health. It is therefore important that signals of gender preference are recognised. It should be stressed that this is a cultural problem and not prescribed by religion, and understanding the difference is an important point for health professionals.
The role of the family
The family unit, which is extended through both marriage and childbirth, is sacred in Islam. The Hadith states ‘Whoever believes in Allah and the Last day should maintain his kinship ties’. Although there are no specific requirements outlined in the Qur'an or Hadith explaining the responsibilities of the family post childbirth, there are cultural traditions. Within the Asian community for example, the new mother is encouraged to rest for 30–40 days. During this time, she is restricted from certain activities and confined to particular foods. Emotional support and practical advice regarding caring for the new baby are often received through family members, including both the mother and the mother-in-law (Klainin and Arthur, 2009).
Klainin and Arthur (2009) suggest that, while this can be comforting to the mother, it can also cause conflicts and emotional frustration, particularly if the relationships are unstable. Having a period of confinement can also generate stress and even isolate the woman from wider society, thus negatively impacting on the woman's mental health.
While family support is important and often beneficial, cultural traditions can, in some instances, burden the mother. For example, it may be that having an extensive network of female relatives caring for the baby could inhibit the maternal-infant bond. Difficulties in bonding with the baby are common, affecting approximately one in five women (Royal College of Midwives, 2012). It is therefore important that health professionals are aware of the whole family unit and the impact it may be having on the mother's mental health.
Biological causes
During pregnancy, oestrogen levels are at their highest. This dramatically decreases postpartum and it is suggested that the withdrawal of steroid hormones at birth may be a risk factor for postpartum depression (O'Hara and Wisner, 2014). Islam recognises mental illness, with the Qur'an explaining that ‘Allah burdens not an individual more than his capability’ (Surah, 2:286). Religious teaching does, however, offer compassion and understanding towards the mentally ill through the verse ‘Mankind has been created weak’ (Surah, 4:28).
This can be contrasted with traditional Islamic medicine, which states that disease can occur when there is a lack of faith and supplication, leading to the person diverging away from Islam (Fonte and Horton-Deutsch, 2005). This can also be demonstrated through the Qur'an being seen as a healer: ‘And We send down the Qur'an such things that have healing and mercy for the believers’ (Surah, 17:82). Acceptance of a biological or scientifically proven reason for perinatal mental health can therefore rest with individual interpretation of these texts.
Muslims believe in the Jinn (the devil), which is described in the Qur'an as ‘fire of scorching wind’ (Surah, 27:163). Islam teaches that humans are given free will and they are tempted by the Jinn to ‘follow different paths’ (Surah, 72:11). There is little connection between the Jinn being the cause for a mental illness; however, some Muslims may believe in Jinn possession from the verse ‘All we can say is that one of our gods may have inflicted some harm on you’ (Surah, 11:54).
A biological cause for perinatal mental health is still not an absolute tangible entity, with many different risk factors predisposing women to mental illness. The Qur'an suggests that good health is associated with a strong spiritual connection; therefore mental illness may cause Muslims to turn again to the spiritual for an explanation. This notion can be positive, as it takes the responsibility away from the person and puts blame on the devil; or an actual belief in Jinn possession can make the person feel guilty for being weak and allowing the devil into their soul out of sin or lack of faith (Islam and Campbell, 2012).
As a result, Muslims may feel a degree of isolation from Western society due to a lack of understanding on the part of health professionals or a sense of shame that may be experienced in the Muslim community. Together, this leads to Muslims under-using the mental health services on offer (Islam and Campbell, 2012).
Health professionals should be aware of the different attitudes that Muslim women may have towards perinatal mental health. Midwives must be sensitive to women's beliefs and be cautious of the stigma that may be associated with mental health in the Muslim community. Services available must be discussed and offered, and perinatal mental health should be normalised when discussed, to help break down the barriers surrounding mental health. In summary, midwives must provide holistic care, where all the spiritual needs are met and support is always offered.
Conclusions and recommendations
This article has discussed the psychosocial and biological factors that may contribute to mental illness during the childbirth continuum. These risks were then discussed within the context of Islam to highlight perinatal mental health from a Muslim perspective.
Religion may be a source for advice and a large part of a Muslim woman's life during the childbirth continuum. Health professionals should therefore be sensitive towards religious beliefs and provide individualised care. This article has also demonstrated the potential difficulties of differentiating religion from culture; and it is therefore important that midwives are aware of this difference.
There is a gap in knowledge in regard to perinatal mental health and Islam, with limited studies on perinatal mental health in British Muslims. There is therefore potential for further research, perhaps taking into account different cultural backgrounds, or the generation of immigrant status. There is also scope to incorporate this into perinatal mental health education. In both undergraduate healthcare education and continued professional education, there should be information given on the significance and impact of culture and religion on mental health.